Dermatology

Which of the following interventions can the nurse delegate to ancillary staff regarding the prevention of pressure ulcers on an elderly dependent patient? a. Repositioning the patient at least every 2 hours b. Assessing the patient s bony prominences every shift c. Educating the family to the importance of healthy skin d. Assisting the patient in the selection of high-protein foods

a. Repositioning the patient at least every 2 hours

A client arrives at the emergency department with a snakebite of the lower left leg. What should the nurse do? A. Immobilize the limb below the level of the heart. B. apply a tourniquet to the affected limb. C. Identify the type of snake causing the bite. D. Apply ice to the skin over the snakebite wound.

A. Immobilize the limb below the level of the heart.

A client comes to the clinic reporting skin lesions. The nurse assesses the lesions and notes they are 0.5 cm in size, elevated and solid, with very distinct borders. Based on the findings, which of the following should the nurse document the presence of? A. Papules B. Macules C. Wheals D. Vesicles

A. papules

A client has had a basal cell carcinoma removed by surgical excision. The nurse instructs the client to watch for indications of potential malignancy in other moles, including which of the following? A. ulceration B. blanching of surrounding skin. C. dimpling D. a raised appearance

A. ulceration

A nurse plans to teach a group of young adults health promotion techniques to reduce the risk of skin cancer. Which of the following should the nurse include? A. Use a topical hydrocortisone cream for sunburn. B. Avoid exposure to the midday sun. C. Wear a sun visor during early afternoon. D. Choose a tanning booth instead of a beach.

B. Avoid exposure to the midday sun.

Following a head injury, the client has thin clear drainage coming from the left ear. The nurse describes this drainage as: 1. Serous 2. Purulent 3. Cerebrospinal fluid 4. Serosanguineous

1. Serous Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should describe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid.

Upon changing the client's dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is: 1. Sterile saline 2. Hydrogen peroxide 3. Povidone-iodine (Betadine) 4. Sodium hypochlorite (Dakin's solution)

1. Sterile saline

When assessing a bedridden client admitted from home, the nurse notes a shallow crater in the epidermis of the clients sacral area. The nurse documents the presence of a pressure ulcer, noting that it is stage 1 2 3 4

2

Which of the following clients has the greatest risk for friction-induced skin breakdown? 1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing her hands 4. An immobile client who slides down in the recliner where he spends the morning hours

3. A client who is cognitively impaired and comforts herself by wringing her hands A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion. The other options represent friction or moisture factors that contribute to skin breakdown.

To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side-lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

3. Elevate the head of the bed as little as possible Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk for injury to underlying tissue and pressure ulcer formation.

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to: 1. Urine 2. Purulent exudates 3. Gastric fluids 4. Serosanguineous drainage

3. Gastric fluids Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.

The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity? 1. Having the client sit up in a chair for 4-hour intervals 2. Keeping the head of the bed in a high-Fowler's position to increase circulation 3. Keeping a written schedule of turning and positioning 4. Encouraging the client to perform pelvic muscle training exercises several times a day

3. Keeping a written schedule of turning and positioning

In reviewing the client's nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat: 1. Fish 2. Eggs 3. Liver 4. Citrus fruits

4. Citrus fruits Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein plays a role in neogenesis, collagen formation, and wound remodeling. Liver contains vitamin A, which is important in epithelialization and wound closure.

The nurse is planning a program on wound healing and includes information that smoking influences healing by: 1. Suppressing protein synthesis 2. Creating increased tissue fragility 3. Depressing bone marrow function 4. Reducing functional hemoglobin in the blood

4. Reducing functional hemoglobin in the blood Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing tissue oxygenation. Antiinflammatory drugs suppress protein synthesis. Radiation creates tissue fragility. Chemotherapeutic drugs can depress bone marrow function.

Which of the following statements best reflects the nurse's role in the health and maintenance of a client's skin? (Select all that apply.) 1. "I'll note on the client's care plan to apply lotion to her dry elbows." 2. "I'm on my way in to turn the client. Will you be able to help me?" 3. "The ancillary staff tells me that her skin is generally very dry." 4. "The pressure ulcer on her hip has really gotten smaller." 5. "Can you bring in some scented lotion for your mom?" 6. "A 1.5-cm reddened area noted on client's left heel."

ANS: 1, 2, 4, 6 One of the nurse's most important responsibilities is to monitor skin integrity and to plan, implement, and assess interventions to maintain skin integrity. The remaining options do not reflect nursing interventions—one reflects ancillary staff, and the other does not really mention the therapeutic role of the request.

Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.) 1. Presence of pain 2. Depth of damage 3. Length and width 4. Presence of drainage 5. Description of drainage 6. Condition of surrounding tissue

ANS: 2, 3, 4, 5, 6 Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.

When targeting a group of clients for health teaching, the nurse should be aware though which group is greater risk for developing malignant melanoma? Clients who are... A. Clients who have brown eyes and are of Asian descent B. Clients who are fair-haired, fair-skinned, and of Celtic descent C. Clients who are olive-skinned, brown-eyed, and of European descent. D. Clients who are dark-skinned and of Native American descent

B. Clients who are fair-haired, fair-skinned, and of Celtic descent

A client with an undiagnosed lesion on the back of his right hand is concerned about the possibility of skin cancer. When the client asks about the most serious type of skin cancer is, the nurse responds based on the knowledge that most malignant tumors are A. basal cell carinomas B. melanomas. C. angiomas. D. squamous cell carcinomas

B. melanomas.

A client is being discharge after surgical excision of a malignant melanoma. Which statement indicates to the nurse as understanding of the dangers of ultraviolet light? A. I'll skip application of sunscreen on cloudy days B. I'll keep a tee shirt on when I go sailing so I don't get sunburned C. I'll reapply my sunscreen every 2 hours when I'm out in the sun. D. I'll use a sunscreen with a solar protection factor of at least 10 when I'm in the sun

C. I'll reapply my sunscreen every 2 hours when I'm out in the sun.

A 49-year-old woman is recovering from a pressure ulcer on her left hip. The patient refuses her lunch today and tells the nurse she fasts for lunch time as part of her weight loss diet. How should the nurse respond to this patient? A. The nurse will explain that fasting is against the hospital policy B. The nurse does not believe in fasting and will scold the patient for her choice of diet C. The nurse informs the patient that fasting will hinder her healing progress D. The nurse respects the patient's choice and does not say anything

C. The nurse informs the patient that fasting will hinder her healing progress

To promote healing for a client with a large wound healing by secondary intention, the nurse recommends a diet high in protein and which of the following? A. Iron B. Folate C. Vitamin C D. Potassium

C. Vitamin C

A client is about to undergo a biopsy of a 6-mm, bluish-red lesion. In addition to a thorough skin examination, the nurse knows the most critical assessment to be made at this time is the status of the client's A. cardiovascular system B. pulmonary function C. white blood cells. D. regional lymph nodes

D. regional lymph nodes

A nurse teaches a wheelchair bound client to reduce the risk of pressure ulcer formation by instructing the client to which of the following? A. move between the bed and the wheelchair every 2 hours B. Make sure that your personal assistant massages your skin daily. C. Be certain to eat a diet that is high in both fiber and fluids D. shift your weight in the wheelchair every 15 minutes

D. shift your weight in the wheelchair every 15 minutes

A client is admitted for treatment of a malignant melanoma of the left upper leg. Initially, the nurse plans to prepare the client for which of the following? A. cryosurgery B. external radiation therapy C. regional chemotherapy D. surgical excision

D. surgical excision

Which of the following characteristics is most likely that of a Stage 2 pressure ulcer? a. Eschar b. Blister c. Deep crater d. Nonblanchable redness

b. Blister

Which of the following assessment observations would be most indicative of healthy wound healing? a. Absence of eschar b. Presence of slough c. Presence of granulation d. Small wound size compared with original wound

c. Presence of granulation

nflammation of the vein at the IV site with redness, swelling, tenderness, and the area warmto touch with burning pain along the vein could be documented as _________________ . a Irritation b Infiltration c Necrosis d Phlebitis

d Phlebitis