Lecture Exam 3-Tissue Integrity/Wound Healing/Pressure Ulcers/ Contact Dermatitis QARs

How does impaired mobility impact tissue​ integrity? (Select all that​ apply.) -Encourages skin breakdown -Creates exudate -Activates allergic response -Increases susceptibility to microorganisms -Promotes pressure ulcer formation

-Encourages skin breakdown -Promotes pressure ulcer formation Rationale Individuals with impaired mobility can experience skin breakdown and pressure ulcers. Exudate and increased susceptibility to microorganisms are infection responses to impaired mobility. Activation of an allergic response is an immune response.

What is the mechanism of action of an​ ointment? (Select all that​ apply.) -Decreases pain -Retards water loss -Lubricates the skin -Inhibits DNA replication -Soothes irritation

-Retards water loss -Lubricates the skin Rationale Mechanisms of action for ointments include lubricating the skin and retarding water loss. Anesthetics decrease pain. Alternative therapy preparations soothe irritation. Antivirals inhibit DNA replication.

Which are nonmodifiable risk factors for the development of skin​ disorders? (Select all that​ apply.) -Diet -Employment -Age -Ethnicity -Genetics

-Age -Ethnicity -Genetics Rationale Nonmodifiable risk factors for skin disorders include​ age, genetics, and ethnicity. Diet and employment can be modified.

The nurse is caring for a client with a pressure ulcer on the right elbow that is covered with eschar. The nurse should document this ulcer as being which​ stage? Stage III Stage II Stage I Stage IV

Rationale A stage IV pressure ulcer may be covered with eschar. Eschar is not present with stage​ I, stage​ II, or stage III pressure ulcers.

The nurse is educating a student about alginate dressings. On what type of pressure ulcer is this type of dressing​ used? (Select all that​ apply.) Stage I Stage IV without eschar Stage II Stage III Stage IV with eschar

Rationale Alginate dressing should be used for pressure ulcers of stage​ II, III, and IV without​ eschar, but not for pressure ulcers of stage I or stage IV with eschar. An alginate dressing is not used for stage​ I, Alginate calcium Tegaderm can be used with stage I.

The nurse is to apply an elastic bandage over a​ client's wound on the right arm. Which nursing assessment should be completed before applying this​ bandage? Pain on a scale from 1 to 10 ​Client's ability to reapply the bandage Adequacy of the circulation in the right arm Wound drainage

Rationale Before applying the​ bandage, the​ client's limb should be inspected for the presence of wound drainage. If drainage is​ present, a dressing is required before applying the elastic bandage. Adequacy of circulation in the limb would be assessed after the dressing has been applied. Pain assessment can be done at any time prior to the application of the bandage. The​ client's ability to reapply the bandage is not a priority before applying the bandage.

The nurse is reviewing the pharmacological profile of a client with a nonhealing wound. Which of the​ client's medications can delay wound​ healing? Hydrocodone​ (Vicodin) Esomeprazole​ (Nexium) Digoxin​ (Lanoxin) Dexamethasone​ (Decadron)

Rationale Corticosteroid agents interfere with wound healing. Digoxin increases the contractility of the heart but has no direct relationship to wound healing. Hydrocodone is an analgesic with no direct association with wound healing. Esomeprazole is a proton pump inhibitor not associated with wound healing.

Which factor contributes to the formation of pressure ulcers in a client and increases the cells​' need for​ oxygen? Immobility Diminished sensation Excessive body heat Inadequate nutrition

Rationale Excessive body heat increases the metabolic rate and the cells​' need for oxygen.​ Immobility, diminished​ sensation, and inadequate nutrition contribute to the formation of pressure​ ulcers, but they do not increase the cells​' need for oxygen.

The nurse identifies that a client admitted for decreased mental status is at risk for a pressure ulcer. Which action assists in maintaining skin hygiene to help prevent a pressure​ ulcer? Using hot water and mild soap during the bath Applying lotion to moist skin after the bath Massaging bony prominences during the bath Monitoring the skin once a week during the bath

Rationale Moisturizing lotions applied directly to moist skin after bathing help maintain skin hygiene and prevent pressure ulcers. Massaging bony prominences can cause friction. Using hot water to bathe the client can dry the skin and cause​ injury, A skin assessment is done on admission and then daily

An​ 88-year-old client who has limited mobility is admitted to the hospital. Which action by the nurse prevents injury to the skin normally caused by​ friction? Placing the client in the prone position Sprinkling baby powder on the sheets to keep the skin dry Avoiding use of a draw sheet when repositioning the client Elevating the head of the bed to a​ 60-degree angle

Rationale To prevent injury to the skin caused by​ friction, the client should be turned every 2 hours using six different body​ positions, which include the prone position. Elevating the head of bed to a​ 60-degree angle, not using a draw​ sheet, and using baby powder cause injury to the skin as a result of friction

When planning care for a client at risk for developing a pressure​ ulcer, the nurse addresses the potential problem of risk for impaired skin integrity. Which nursing intervention assists in meeting the goals of this​ diagnosis? (Select all that​ apply.) Placing the client in the​ side-lying position only Using positioning devices Avoiding massaging bony prominences Inspecting the skin every day Keeping the head of the bed elevated more than thirty degrees

Rationale Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown and assist in meeting the goals of this diagnosis. Avoid placing the client in a​ side-lying position only or keeping the head of bed elevated more than thirty degrees because these positions can put pressure on specific body areas

A client with type 1 diabetes mellitus has a blister on the left heel that resulted from improperly fitting shoes. The nurse should document this ulcer as being which​ stage? Stage I Stage IV Stage II Stage III

Rationale A stage II pressure ulcer is considered to be superficial and appears as a blister. Stage I ulcers have intact skin that doesn​'t blanch when pressed. Stage III pressure ulcers are deep open wounds with necrosis of subcutaneous tissue. Stage IV pressure ulcers have​ full-thickness skin loss with extensive tissue damage and necrosis

In which wound healing phase does hemostasis​ occur? Inflammatory phase Maturation phase Approximation phase Proliferative phase Granulation phase

Inflammatory Phase Rationale Hemostasis occurs in the inflammatory phase and results from blood vessels vasoconstricting in response to the​ injury, fibrin deposits in the​ area, and blood clot formation. The proliferative phase is characterized by the addition of collagen and the formation of granulation tissue. The approximation phase is part of the proliferation phase as collagen forms and strengthens the edges of the wound. The maturation phase occurs when collagen formation becomes more organized and the scar becomes​ stronger, but may also lead to​ keloids, which are more prevalent in individuals with dark skin. The granulation phase occurs when capillaries grow on the wound to increase blood supply to the area. As they form a​ network, this tissue becomes translucent red and is called granulation tissue.

Julie Smith is a​ 44-year-old client who underwent a left mastectomy 2 days ago. Which factor will put Ms. Smith at the highest risk of a wound​ infection? Maintaining her BMI of 23 Starting chemotherapy in 1 week Continuing to walk every day Eating a protein bar every day

Julie Smith is a​ 44-year-old client who underwent a left mastectomy 2 days ago. Which factor will put Ms. Smith at the highest risk of a wound​ infection? Maintaining her BMI of 23 Starting chemotherapy in 1 week Your answer is correct. Continuing to walk every day Eating a protein bar every day Review Only Learning Objective Differentiate the​ pathophysiology, etiology, risk​ factors, prevention, and clinical manifestations. Rationale Eating a balanced diet high in​ protein, and exercising and maintaining an ideal body weight promote optimal wound healing. Such medications as​ anti-inflammatory drugs and antineoplastic agents may make a client more susceptible to infection due to suppression of the immune system. Taking pain medications does not increase risk of infection.

Mr. Brown is being treated for pressure ulcers. Mr. Brown has dementia and limited​ mobility, and he lives with his​ daughter, spending most of his day sitting in a chair. What should you suggest to Mr.​ Brown's daughter to help reduce his risk for pressure​ ulcers? ​"Reposition Mr. Brown in the chair every 3​ hours." ​"Have Mr. Brown stay in bed rather than sit in a​ chair." ​"Place a memory foam pad on Mr.​ Brown's chair." ​"Have Mr. Brown sit in a more comfortable​ chair."

Mr.​ Brown's daughter can place a memory foam pad on the chair to reduce pressure on Mr.​ Brown's buttocks. Other devices to reduce pressure on body parts include gel flotation pads and pillows and wedges made of​ foam, gel,​ air, or fluid. Changing the chair Mr. Brown sits in or having him stay in bed will​ increase, not​ reduce, his risk of pressure ulcers. Repositioning should occur every 2​ hours, not every 3 hours.

The nurse is providing care for a client with a wound infection. Which diagnostic test is necessary to determine the antibiotic choice for this​ client? Complete blood cell count Urinalysis Culture and sensitivity Electrolyte panel

Rationale A client diagnosed with a wound infection will require a culture and sensitivity prior to the initiation of antibiotic therapy. The other diagnostic tests may be​ ordered, but the culture and sensitivity will be used to determine the most appropriate antibiotic to treat the client​'s wound infection.

The charge nurse has just received the report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ ulcers? (Select all that​ apply.) The client who is 92 years old The client who is admitted to an acute care unit The client who has type 1 diabetes mellitus The client who has a history of anorexia nervosa The client who is on bed rest

Rationale A client on bed rest is​ immobile, which creates a risk for developing pressure ulcers. An older client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissue. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure ulcer.

A client with a wound infection has been receiving cephalexin 500 mg​ orally, 4 times a day. The lab report shows sensitivity to clindamycin. What action would the nurse expect from the health care​ provider? The provider will increase the dose of cephalexin. The provider will change the antibiotic to clindamycin. The provider will add clindamycin to the client​'s profile. The provider will not make any changes to the client​'s therapy.

Rationale A culture and sensitivity test is performed when infection is suspected. A sensitivity report determines which medication is most effective in treating the infection. The nurse can expect the provider to change the client​'s therapy to the medication that is most appropriate to treat the infection.

The nurse is caring for a client with a surgical wound. Which finding would indicate the need for further​ intervention? Wound is red and edematous with a foul odor Wound pain is rated as a 1 on a scale of 0 to 10 Wound edges are well approximated Wound dressing is dry and intact

Rationale Assessment data that require further intervention is a wound that is​ red, edematous, and has a foul odor. These findings indicate a wound infection. The other assessment findings are expected and would not require further intervention by the nurse.

The nurse is assessing a client with a large abdominal surgical wound. Which assessment would concern the nurse that puts the client at risk of the complication of​ dehiscence? ​(Select all that​ apply.) The client smokes a half pack of cigarettes per day. The client has vomited 6 times in the last 4 hours. The client is​ obese, with a BMI of 38. The client is 12 hours postop. The client shows signs of dehydration.

Rationale Dehiscence usually involves an abdominal​ wound; the layers above and below the skin separate. The bowel may protrude into the opening. Risk factors for dehiscence include​ obesity, poor​ nutrition, multiple​ trauma, suture​ failure, excessive​ coughing, vomiting, or dehydration. It is most likely to occur 4dash-5 days postoperatively. Smoking is not an identified risk factor for dehiscence.

The nurse is caring for a client admitted with a pressure ulcer. Which data should the nurse document when assessing the pressure​ ulcer? (Select all that​ apply.) Home management of the pressure ulcer Stage of the ulcer Color of the wound bed Signs of infection Integrity of the surrounding tissue

Rationale Document the stage of the pressure​ ulcer, Color of the wound​ bed, Integrity of the surrounding​ tissue, and signs of infection. Assessment of home management does not need to be documented.

A client who is confined to bed is at risk for developing a pressure ulcer. What support surface should the nurse request for this​ client? Memory foam mattress Gel flotation pads Kinetic bed Alternating pressure mattress

Rationale For clients who are confined to​ bed, the support surface needs to include a kinetic bed that provides oscillation therapy. Gel flotation​ pads, a memory foam​ mattress, and an alternating pressure mattress help to reduce pressure on specific body parts but are not the recommended support surface.

The nurse is caring for a client with a surgical wound. Which are the most appropriate goals for the​ client? ​(Select all that​ apply.) The client will be​ comfortable, with pain at an acceptable level. The client will discontinue medications that may interfere with healing. The client will engage in activities that promote wound healing. The client will remain free of wound infection. The client will maintain adequate hydration.

Rationale Goals for clients with a healing wound center around adequate​ nutrition, hydration, infection​ prevention, and promotion of optimal wound healing. Pain control is also important for the client. The client should not stop taking prescribed medications without talking to the primary​ provider, even if the medications have the potential to delay wound healing or increase the risk of​ infection, such as corticosteroids.

The nurse is caring for a client with a stage I pressure ulcer to the sacrum. Which product should the nurse use to help increase blood supply to the skin of this pressure​ ulcer? Transparent dressing Hydrogel dressing Granulex ​ Vacuum-assisted closure

Rationale Granulex is a product that increases blood supply to the intact skin of a stage I pressure ulcer. A transparent or hydrogel dressing does not increase blood supply to intact skin of a stage I pressure ulcer.​ Vacuum-assisted closure increases the blood supply but should only be used on a stage IV pressure ulcer

A client has just undergone femoral popliteal bypass surgery and has an incision with staples in the right groin. The nurse assesses a large swelling around the incision and notes that the right thigh is noticeably larger than the left. The client is pale and diaphoretic with a blood pressure of​ 72/48 mmHg. Which complication would the nurse​ suspect? Evisceration Infection Dehiscence Hemorrhage

Rationale Internal hemorrhage may be seen as a swelling or distention in the surgical area. It can be caused by a clot dislodging or a missed​ suture, among other things. It is an emergency that requires pressure to be applied to the area. The client may need to go back to the operating room. Wound​ infection, dehiscence,​ evisceration, and keloid formation generally occur later in the process and do not present with these symptoms.

A client is seen in the clinic after being discharged from the hospital for treatment of a pressure ulcer. Which client outcomes demonstrate to the nurse that the treatment goals are being​ met? ​(Select all that​ apply.) The wound has decreased in size. The​ client's BMI is​ 16, and weight is down by 4 pounds. There is greenish exudate on the dressing. The client has enrolled in a smoking cessation program. The client and family demonstrate an understanding of preventive care measures.

Rationale Regular evaluation of nursing and client goals are important. When the client and family demonstrate understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation​ program, it indicates that nursing interventions and education have been effective. Greenish exudate indicates a possible​ infection; and the​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.

Mr. Mathews is a​ 64-year-old African American man admitted to your unit with cellulitis. He reports that he has diabetes mellitus and shows you a scar from a previous surgery that has keloids. Which wound healing phase has the client​ achieved? Inflammatory phase Maturation phase Proliferative phase Hemostatic phase

Rationale Scars become stronger and more organized during the maturation phase. In some​ individuals, particularly those with dark​ skin, the scar becomes hypertrophic and is called a keloid. The inflammatory and proliferative phases are the first two phases of wound healing. There is no hemostatic phase.

Mr. Ramirez asks the nurse about nonpharmacologic therapies to help heal his large surgical wound. Which therapies are appropriate for the​ client? ​(Select all that apply​.) Biosurgery Hyperbaric oxygen therapy NSAIDs Specialty bandages

Rationale Specialty​ bandages, hyperbaric oxygen​ therapy, and biosurgery are all examples of nonpharmacologic therapies. NSAIDs are​ anti-inflammatory medications used to treat pain and inflammation.

Which treatments are appropriate for the wound complication of​ infection? ​(Select all that​ apply.) Antibiotics Manual pressure Dressing changes Emergency surgery Debridement

Rationale The client who experiences an infection in a wound would receive​ antibiotics, debridement, and dressing changes. Manual pressure is the treatment for the complication of hemorrhage. Emergency surgery is the treatment for hemorrhage and dehiscence.

Ms. Greene is admitted to the hospital with a temperature of​ 102.5°F. She had abdominal surgery a week ago. The wound is draining a yellowish exudate and the surrounding skin is warm to the touch. The nurse receives an order for a culture and sensitivity of the drainage. What would the nurse include in the explanation of this lab test to the​ client? Indicates whether another surgery is needed Indicates that a special dressing should be used Indicates how much pain to expect Indicates which antibiotic will be most effective for the infection

Rationale The culture identifies the organism responsible for the infection while the sensitivity determines which medication will be most effective in treating it. The lab test does not indicate the​ client's pain​ level; whether additional surgery is​ needed; or which type of dressing to use.

While assessing the skin of a surgical​ client, the nurse observes erythema to the left scapulae. What is the best action for the nurse to take before reassessing the skin to determine if the erythema is a pressure​ ulcer? Covering the area with a dressing Massaging the scapulae with lotion Repositioning the client Applying a warm blanket

Rationale The nurse needs to reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage I pressure ulcer. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing is not the best action before reassessing the client.

A client is being assessed by the health care provider for potential therapies for his sternal​ wound, which include hyperbaric oxygen​ therapy, skin​ grafting, and biosurgery. What would the nurse expect to observe when visualizing the​ client's wound? ​(Select all that​ apply.) Wound has impaired healing Wound Is extremely large Wound is in the maturation phase Wound has eviscerated Wound has necrotic tissue or slough

Rationale There are several therapies that may be useful for wounds with impaired healing. Biosurgery with sterile maggots may be used in wounds with necrotic tissue and slough to digest the unhealthy tissue. Hyperbaric oxygen therapy improves oxygenation in nonhealing wounds. Skin grafts may be appropriate for some clients with nonhealing wounds. The size of the wound​ doesn't determine the treatment. An eviscerated wound requires surgery. Wounds in maturation are healed.

A nurse identifies that a client has a pressure ulcer on the sacrum. Which assessment finding indicates that this is a stage III pressure​ ulcer? Damage identified to muscle and bone Skin loss to the dermis ​ Non-blanchable erythema of intact skin Necrosis of subcutaneous tissue

Rationale This client has a stage III pressure​ ulcer, which indicates that damage to the subcutaneous tissue has occurred. The necrosis extends down to but not through the underlying fascia. Exposed muscle and bone indicates a stage IV pressure ulcer. An area of nonblanchable erythema of intact skin indicates a stage I pressure​ ulcer, and skin loss to the dermis indicates a stage II pressure ulcer.

A nurse finds a nurse colleague supporting a client​'s abdomen with a large dressing soaked in sterile normal saline. The client is in bed with knees​ bent, and states that something open double quote"gave way.close double quote" What does the nurse tell the surgeon has occurred with this​ client? The client​'s abdominal wound has dehisced or eviscerated. The client is experiencing a severe postop infection. The client​'s ​vacuum-assisted closure device is malfunctioning. The client is experiencing intractable pain.

Rationale This scenario describes immediate intervention for wound dehiscence or evisceration. It is not an appropriate intervention for intractable​ pain, malfunction of a​ vacuum-assisted closure​ device, or postop infection.

Which action maintains skin hygiene for clients at risk for pressure​ ulcers? (Select all that​ apply.) Scrubbing the skin to clean it thoroughly when bathing Cleaning the skin immediately if exposed to urine or feces Assessing the skin upon admission and then daily using the same screening tool Avoiding exposure to high humidity Treating dry skin with moisturizing lotions directly applied to moist skin after bathing

Rationale To maintain skin hygiene for clients at risk for pressure​ ulcers, assess the skin upon admission and then​ daily, using the same screening​ tool, treat dry skin with moisturizing lotions directly applied to moist skin after​ bathing, and immediately clean the skin if exposed to urine or feces. Do not scrub the​ client's skin when​ bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low​ humidity, not high humidity.

You are completing a health history on​ 32-year-old Walter​ Powell, who is in the healthcare​ provider's office today with complaints of an intermittent skin rash over the last 2 weeks. Which statement would indicate that he may have an allergic​ condition? ​ -"I have lost 5 pounds since my last​ visit." -"I have a sister who has​ eczema." -"I occasionally have to get up at night to use the​ bathroom." -"My blood pressure has been a little high since last​ week."

​-"I have a sister who has​ eczema." Rationale The nurse collects information during the assessment of the client that includes risk factors for allergic type skin alterations. Risk factors for allergic reactions include hereditary and genetic​ predisposition, repeated exposure to the same allergens over​ time, and individual sensitivity to specific allergens. The client statement of having a sibling with eczema means that he is at increased risk of having an inflammatory skin condition himself. Reports of elevated blood​ pressures, weight​ loss, and nocturia are unrelated to allergic skin conditions.

The nurse is performing a scratch test on a client with suspected allergic contact dermatitis. The client​ states, "I​ don't understand why​ I'm only getting this reaction now. This​ didn't happen to me the first time I used this​ detergent." Which response by the nurse is the most​ appropriate? -"Once you stop using the​ detergent, your rash will disappear right​ away." ​-"The first contact sensitized you to the allergen. You​ don't have an allergic reaction until the next exposure to the​ allergen." ​-"Your body is experiencing a delayed hypersensitivity reaction to the allergen and sending T cells to attack the​ allergen." ​-"Sometimes it takes time for your body to react. In some people it may be years until they​ react."

​-"The first contact sensitized you to the allergen. You​ don't have an allergic reaction until the next exposure to the​ allergen." Rationale With allergic contact​ dermatitis, the first exposure to the allergen sensitizes the client to the​ allergen, and manifestations of the allergy do not manifest until subsequent exposures. Stating that sometimes it takes time for the body to react does not explain the process to the client. With allergic contact​ dermatitis, removing the allergen does not guarantee rapid resolution of symptoms. In some​ cases, symptoms may remain for up to three weeks. Explaining the course of the condition also does not answer the​ client's question. The explanation of the pathology of allergic contact dermatitis may be too technical for the client and does not answer the​ client's specific question about the timing of symptoms.

The nurse is performing a health history on a client who has been intermittently experiencing a​ red, itchy rash on the feet for the past 2 months. The client thinks it may be wool socks that are causing the rash. Which assessment question will allow the nurse to distinguish whether the client has allergic or irritant contact​ dermatitis? ​-"How much does the rash​ itch?" -"Do you have a fever when you have the​ rash?" ​-"Does the rash go away quickly after you take the socks​ off?" -​"Does the rash look redder than when it first​ began?"

-"Does the rash go away quickly after you take the socks​ off?" Rationale Asking about the course of the rash is the best way to distinguish between allergic and irritant contact dermatitis because irritant contact dermatitis resolves quickly after removal of the irritant. Allergic contact dermatitis may linger for up to 3 weeks following removal of the allergen. Asking about the severity of itching would not help distinguish between the two types of contact dermatitis. Asking if the rash looks redder or if fever accompanies the rash helps assess for the presence of infection but does not help distinguish between the two types of contact dermatitis.

The nurse is providing education to a client with allergic contact dermatitis caused by a new brand of sunscreen. Which statement made by the client indicates appropriate understanding of the teaching​ session? -"I have been sleeping well since I started using the corticosteroid​ cream." ​-"I have been putting petroleum jelly on my rash with the corticosteroid​ cream." ​-"My rash feels hot and​ painful, but it​ didn't when it first​ started." ​-"I will only use this sunscreen once a week until my rash gets​ better."

-"I have been sleeping well since I started using the corticosteroid​ cream." Rationale If the client is sleeping​ well, then pruritus has been properly managed. The client should avoid the precipitating​ allergen, not use it less frequently. If the​ client's rash is newly hot and​ painful, this could be a sign of an infection that necessitates further treatment. Allergic contact dermatitis should be treated with drying lotions and​ treatments, not emollients that prevent water loss like petroleum jelly.

Jackson​ Michaels, a​ 65-year-old male, is seen by a dermatologist for a suspicious skin esion on the right forearm. The healthcare provider believes that the lesion is cancerous. Mr. Jackson is upset and asks what the next step for him will be. Which response by the nurse is the most​ appropriate? ​-"You will require months of chemotherapy to treat this​ cancer." ​-"The provider has ordered scratch tests for next week. We will know more after we do the procedure and get the​ results." ​-"You will need to have a culture done on the lesion to determine if you have​ cancer." ​-"The provider has ordered a biopsy of the lesion. Prognosis and treatment will be determined once the results are​ back."

-"The provider has ordered a biopsy of the lesion. Prognosis and treatment will be determined once the results are​ back." Rationale Skin lesions that are believed to be cancerous require a skin biopsy. Once the results of the biopsy confirm​ cancer, a treatment plan can be initiated. Telling the client he will require months of chemotherapy before a definitive diagnosis is made is not appropriate. Cultures are taken from skin​ wounds, not skin lesions believed to be cancerous. Scratch tests are used to diagnose​ allergies, not cancer.

The nurse is applying ointment to the affected skin area of a client with contact dermatitis. The client asks the nurse how this treatment is different from what was prescribed for the allergic dermatitis her husband had. Which response by the nurse is the most​ appropriate? ​-"Topical antibiotics are always applied in conjunction with calcineurin inhibitors for irritant contact​ dermatitis." -"Treatment for irritant contact dermatitis focuses on reducing water loss from the​ skin." -"Treatment for irritant contact dermatitis focuses on promoting drying out the​ rash." -"Topical or oral corticosteroids are the primary treatment for irritant contact​ dermatitis."

-"Treatment for irritant contact dermatitis focuses on reducing water loss from the​ skin." Rationale Because irritant contact dermatitis manifests with​ dry, scaling​ skin, treatment focuses on reducing water loss from the skin through the use of occlusive dressings and​ petroleum-based emollients. Allergic contact​ dermatitis, not irritant contact​ dermatitis, is treated with corticosteroids and by drying out the rash. Topical antibiotics are only used if the client develops a secondary infection.

You are providing home care teaching for​ 22-year-old Heidi​ Loeffler, who is diagnosed with a nickel allergy. She is prescribed a topical corticosteroid cream to apply to her contact dermatitis for 2 weeks. Which teaching point is most appropriate for you to provide to Ms.​ Loeffler? -"You can stop using the cream before the 2 weeks are up if your rash gets better before​ that." ​-"You can wear jewelry with nickel in it if you only wear it for part of the​ day." ​-"You should make sure any metal buttons or snaps on your clothes​ don't directly touch your​ skin." ​-"You can scratch the rash gently if the itching is too much to​ bear."

-"You should make sure any metal buttons or snaps on your clothes​ don't directly touch your​ skin." Rationale Ms. Loeffler should place a barrier between the allergen and the​ skin, including any metal snaps on her clothing. She should avoid contact with the allergen​ altogether, not just reduce contact. She should use the corticosteroid cream for the entire prescribed​ time, not just until it gets better. Ms. Loeffler should avoid scratching since it increases the risk of infection.

If a client​'s contact dermatitis develops a secondary​ infection, which medication will most likely be added to the treatment​ plan? -A topical corticosteroid -An oral antihistamine -An oral antiviral medication -A topical antibiotic

-A topical antibiotic Rationale If a client develops a secondary bacterial infection with​ dermatitis, a topical antibiotic will be added to the treatment plan. A medication to reduce inflammation or​ itching, such as an antihistamine or​ corticosteroid, would not treat the infection. An antiviral medication is not used because the secondary infection is most likely a bacterial one.

The nurse reviews a laboratory test prescribed for a client and considers that poor wound healing might be due to a nutritional imbalance. Which laboratory test did the healthcare provider prescribe for this​ client? -Leukocytes -Albumin -Hemoglobin -Coagulation studies

-Albumin Rationale The albumin level determines nutritional​ status; a value below 3.5​ g/dL indicates poor nutrition. The client could be at risk for poor healing and infection. Hemoglobin level is used to measure oxygen delivery to the skin. Leukocytes are used to determine if an infection is present. Coagulation studies are used to determine risk for bleeding or insufficient blood flow to a region.

When instructing a client about application of a topical corticosteroid cream​ medication, which instructions would be​ correct? -Cleanse the affected area with an exfoliating​ soap, dry the​ area, and apply the prescribed cream. -Apply talcum powder to absorb moisture before applying the prescribed cream. -Apply a thin layer of cream to slightly damp affected area. -Apply a thick layer of cream in a circular motion beginning at the center of the affected area.

-Apply a thin layer of cream to slightly damp affected area. Rationale Corticosteroid creams should be applied in a thin layer. Leaving the affected area slightly moist will enhance their absorption. The skin should be clean and slightly damp but should not be washed with an exfoliating​ soap, which would be harsh and damage the skin. Talcum powder will reduce the absorption of the corticosteroid cream.

A client is prescribed a medicated lotion to apply to a skin rash. What should the nurse teach the client about applying this​ medication? -Place the lotion on the skin -Apply after bathing -Cover the areas with an occlusive dressing -Wrap the areas with a warm towel after applying

-Apply after bathing Rationale When using a​ lotion, the client should be instructed to apply it after bathing while the skin is slightly damp. The lotion should be thoroughly rubbed into the skin and not just placed onto the skin. The area does not need to be covered with an occlusive dressing or wrapped with a warm towel after applying.

A client has multiple areas of bleeding underneath the epidermal layer of the skin caused by broken blood vessels. Which actions should the nurse prepare to provide to this​ client? (Select all that​ apply.) -Apply ice to the areas -Assist with debridement -Administer analgesics as prescribed -Apply soothing lotions to affected areas -Cover areas with​ sterile, absorptive bandages

-Apply ice to the areas -Administer analgesics as prescribed Rationale The client has bruising. Interventions for bruises include applying ice to the areas and administering analgesics as prescribed. Debridement would be appropriate to remove eschar. Soothing lotions are used for pruritus. Covering the areas with sterile absorptive bandages would be used for wounds with exudate.

Latasha​ Montgomery, a​ 23-year-old college​ student, is scheduled for vaccinations before leaving on a trip to South America. What should the nurse instruct Latasha to do to prevent skin damage while​ vacationing? -Apply sunscreen -Wear sleeveless shirts -Bathe every other day -Increase hydration with water

-Apply sunscreen Rationale Regardless of skin​ color, all types and tones of skin can be damaged by ultraviolet exposure. The​ nurse's role includes teaching all individuals to prevent sunburn and prevent the future development of skin cancer by using sunscreen. Bathing every other day and hydrating with water will not prevent skin damage. The nurse should instruct the client to wear protective clothing when outdoors. Sleeveless shirts may not be sufficient to prevent sun damage to the​ client's arms.

The nurse is completing discharge teaching for a client with a skin infection related to contact dermatitis. Which information should the nurse include to assist the client in managing this skin infection at​ home? (Select all that​ apply.) -Avoid allergen that caused initial lesion -Seek medical attention if lesion becomes painful -Stop antibiotics when redness disappears -Use mild soap to clean skin -Keep nails trimmed short

-Avoid allergen that caused initial lesion -Seek medical attention if lesion becomes painful -Use mild soap to clean skin -Keep nails trimmed short Rationale The nurse needs to include client education on avoiding the precipitating allergen and using a mild soap to avoid further irritating the skin while at home. The nurse needs to include client education on seeking medical attention if lesion becomes​ painful, which will assist in wound healing. The nurse needs to include client education on the importance of practicing personal hand​ hygiene, which will assist in wound healing and avoid the spread of infection. The nurse needs to include client education on keeping the nails trimmed​ short, which will prevent additional skin damage if the lesion is accidentally scratched. Stopping antibiotics when redness disappears will not assist in wound healing. It is important that the nurse provides client education on completing the full course of antibiotics as prescribed.

Timothy​ Hagen, a​ 16-year-old client, is prescribed an antibacterial medication to treat a skin infection on both arms. What should the nurse instruct Timothy about this​ medication? -Cover the areas with an occlusive dressing -Avoid exposure to sunlight -Do not use with OTC agents containing peroxide -Treatment may take several weeks

-Avoid exposure to sunlight Rationale Advise the client to avoid exposure to sunlight and ultraviolet light when using an antibacterial agent.​ Anti-acne agents should not be used with OTC preparations containing salicylic​ acid, benzoyl​ peroxide, or sulfur. The full therapeutic effects of​ antivirals, not​ antibiotics, may take several weeks. An occlusive dressing is not required when taking an antibacterial as treatment for a skin infection.

To find possible precipitating causes for contact​ dermatitis, it is most important for the nurse to ask about what factor during the health​ history? -Changes in detergents -Severity of symptoms -Changes in itching -Chief complaint

-Changes in detergents Rationale It is most important for the nurse to ask about any new detergents or other household chemicals​ (e.g., medications,​ soaps, skin care​ agents, or​ cosmetics) to find possible precipitating causes for contact dermatitis. Asking about changes in​ itching, severity of​ symptoms, and the​ client's chief complaint are important for assessing the nature of the​ dermatitis, but are not specific to finding the precipitating cause.

Which is an​ age-related change in the skin that makes older clients more susceptible to contact​ dermatitis? -Difficulty healing -Less exposure to allergens -Improved skin barrier function -Faster turnover of the stratum corneum

-Difficulty healing Rationale With​ aging, the skin decreases in​ thickness, which leads to impaired skin barrier function and delayed wound healing. Older adults have slower turnover of the stratum​ corneum, not faster. Older adults also experience a greater exposure and sensitization to allergens over​ time, not less.

The nurse is teaching a young adult client about risk factors likely to cause allergic skin reactions. Of the​ possibilities, which ones would the nurse identify as possible risk​ factors? (Select all that​ apply.) -Exposure to soap -Infrequent hand washing -Dry environment -Exposure to plants -Exposure to perfumes

-Exposure to soap -Exposure to plants -Exposure to perfumes Rationale ​Soaps, perfumes, and other chemicals are possible triggers of allergic skin reactions. Plants like poison ivy are also triggers for allergic contact dermatitis. Moist environments and frequent hand​ washing, rather than dry environments and infrequent hand​ washing, are also risk factors for developing contact dermatitis.

While applying lotion to the skin of an older​ client, the client asks why it is more important to take better care of her skin now than when he was younger. Which dermatological features will the nurse describe to the​ client? ​(Select all that​ apply.) -Faster wound healing -Greater sensitization to allergens over time -Decreased turnover of the outer skin layer -Impaired skin barrier function -Increased efficiency of blood circulation to skin

-Greater sensitization to allergens over time -Decreased turnover of the outer skin layer -Impaired skin barrier function Rationale With​ age, the turnover of the outer skin layer of the skin​ (stratum corneum)​ decreases, which results in​ slower, not​ faster, wound healing. With​ age, greater exposure and sensitization to allergens​ occurs, causing older adults to be at greater risk for allergic contact dermatitis. Older adults also have impaired skin barrier function.​ However, older adults are less likely to develop irritant contact dermatitis due to the​ decreased, not​ increased, efficiency of blood circulation to the skin.

What are the categories of skin​ disorders? (Select all that​ apply.) -Inflammatory -Excoriations -Macules -Neoplastic -Infectious

-Inflammatory -Neoplastic -Infectious Rationale The three groups of skin disorders are​ infectious, inflammatory, and neoplastic. Macules are a type of primary lesion. Excoriations are a type of secondary lesion.

A client with allergic contact dermatitis is scheduled for a skin test in which small amounts of an allergen will be injected into the skin on the arm. Which test will the nurse educate this client about prior to​ performing? -Patch test -IgE antibody test -Scratch test -Intradermal test

-Intradermal test Rationale An intradermal test involves the injection of small amounts of allergen into the skin on the arm. A patch test involves the application of an adhesive patch with common allergens on the back. A scratch test involves the application of small amounts of allergens to the skin. An IgE antibody test is a blood test for allergen antibodies.

While conducting a routine physical​ examination, the nurse determines that a client is experiencing hyperplasia of melanocytes. What did the nurse assess to come to this​ conclusion? -Cherry hemangioma -Purpura -Liver spots -Double chin

-Liver spots Rationale-Hyperplasia of melanocytes can cause small areas of​ hyperpigmentation, or liver spots. Purpura is caused by the flattening of the​ dermal-epidermal junction. A double chin is caused by redistribution of adipose tissue. A cherry hemangioma is caused by proliferation of capillaries in the dermis.

Which conditions would require IgE antibody blood tests for allergen responses rather than skin​ testing? (Select all that​ apply.) -Medications that could trigger false positives -Life-threatening allergic reaction -Immediate allergen response -Delayed allergen response -Very large areas of contact dermatitis

-Medications that could trigger false positives -Life-threatening allergic reaction -Very large areas of contact dermatitis Rationale A client who experiences a​ life-threatening allergic​ reaction, is taking medication that could trigger false positive​ results, has very large areas of contact​ dermatitis, or has certain skin conditions will need to have blood tests for IgE antibodies rather than skin tests. Skin tests are commonly used to identify delayed and immediate allergen responses.

Which pathological finding characterizes irritant contact dermatitis but not allergic contact​ dermatitis? -Damage to the dermis and epidermis -Pruritus -Rash confined to area of contact with allergen or irritant -Not a hypersensitivity response

-Not a hypersensitivity response Rationale Both types of contact dermatitis are characterized by pruritus​ (itching), damage to the dermis and​ epidermis, and a red rash confined to the area of contact with the allergen or irritant. Irritant contact dermatitis is not a hypersensitivity​ response, unlike allergic contact dermatitis.

A client is diagnosed with a severe case of allergic contact​ dermatitis, which covers​ 20% of the​ client's body. Which treatment can the nurse anticipate will be prescribed for this client that is specific to severe allergic contact​ dermatitis? -Wet dressings -Antipruritic medications -Topical antibiotics -Oral corticosteroids

-Oral corticosteroids Rationale The nurse can anticipate the healthcare provider ordering oral corticosteroids for a client with a severe case of dermatitis. Antipruritic medications will be ordered for a client with a minor case of​ dermatitis, not a severe case. Wet dressings will be ordered if the client has dermatitis with weeping​ lesions, regardless of whether or not the dermatitis is severe. Topical antibiotics will be ordered if the client has dermatitis that has lesions with secondary​ infections, regardless of whether or not the dermatitis is severe.

The nurse carefully inspects a skin lesion that the nurse believes is due to contact dermatitis. Besides​ inspection, what other technique is important for the nurse to use during the nursing assessment of this​ client? -Percussion -Palpation -Auscultation -Biopsy

-Palpation Rationale Besides​ observation, the nurse will palpate the lesion to determine its surface characteristics. The nurse will not use percussion or auscultation techniques. Nurses do not perform biopsies.

Maria​ Gonzalez, a​ 27-year-old dental​ hygienist, is experiencing problems with intermittent allergic skin reactions over small areas of her hands. She states that the problem developed over the last month. Her healthcare provider has suggested further evaluation of this condition. You anticipate an order for which diagnostic​ test? -IgE antibody testing -Urinalysis -Patch testing -Complete blood count

-Patch testing Rationale The most common type of diagnostic study used to identify the source of delayed allergic alterations is the patch test. This involves placing an adhesive patch with common allergens on the back between the scapulae to determine whether or not there is an allergic reaction. IgE antibody testing is only used for​ life-threatening allergic​ reactions, for large areas of contact​ dermatitis, or if medications could trigger false positive results. Other tests such as a CBC and urinalysis are not diagnostic of allergic skin conditions.

What are the goals of treatment for an alteration in skin​ integrity? (Select all that​ apply.) -Maximize mobility -Promote healing -Control the severity -Improve perfusion -Prevent infection

-Promote healing -Control the severity -Prevent infection Rationale Goals of treatment for the client with an alteration in tissue integrity include promoting​ healing, preventing​ infection, and controlling the severity of the skin alteration. Goals of treatment for the client with an alteration in tissue integrity do not include maximizing mobility or improving perfusion.

The nurse is discussing alternative therapies with the mother of a pediatric client with chronic contact dermatitis. Which therapies would the nurse​ suggest? (Select all that​ apply.) -Peppermint -Rice bran broth -Aloe vera -Vitamin C -Probiotics

-Rice bran broth -Aloe vera -Probiotics Rationale Aloe vera​ (applied topically), rice bran broth​ (used to bathe the​ skin), and probiotics​ (administered orally) are all common alternative therapies used to relieve symptoms of contact dermatitis in pediatric clients.​ Chamomile, not​ peppermint, and vitamin​ B12, not vitamin​ C, are other alternative​ therapies, although vitamin B12 may aggravate contact dermatitis in some cases.

The nurse is assessing a client with a red rash on the leg. Which assessment findings will differentiate the rash as allergic or irritant contact​ dermatitis? -Erythema -Vesicles -Scaling -Edema

-Scaling Rationale Both allergic and irritant contact dermatitis cause​ erythema, edema, and vesicles.​ However, only irritant contact dermatitis causes scaling and skin dryness.

Which approaches can be used to obtain a skin​ biopsy? (Select all that​ apply.) -Shaving -Punch -Excision -Culture -Incision

-Shaving -Punch -Excision -Incision Rationale Skin biopsies can be obtained through​ punch, incision, excision or shaving. Cultures are used to identify infections obtained from tissue​ samples, wounds,​ drainage, lesions, or serum.

What is included in the assessment of the​ integument? (Select all that​ apply.) -Texture -Temperature -Reflexes -Nails -Turgor

-Texture -Temperature -Nails -Turgor Rationale The assessment of the integument includes the​ nails, turgor,​ texture, and temperature. Reflexes are a part of the neurologic and musculoskeletal assessments.

The nurse suggests to a mother that her child​'s rash should be examined instead of using an​ over-the-counter topical corticosteroid preparation on the skin area. Why did the nurse make this suggestion to the​ mother? -The rash is located on the child​'s upper thighs. -The nurse does not believe the mother​'s description of the rash. -Topical​ over-the-counter preparations are not strong enough to treat the rash. -The child is under one year of age.

-The child is under one year of age. Rationale Topical corticosteroids should not be used in infants under the age of one because of the risk of​ (rapid) systemic absorption. The location of the rash is not an issue. There is no reason for the nurse not to believe the mother​'s description of the rash. Topical​ over-the-counter preparations are sufficient to treat minor skin rashes and irritations.

The nurse is preparing information on skin health for a community health fair. Why should the nurse include the importance of older individuals using​ sunscreen? -There is less eccrine and apocrine activity. -The subcutaneous tissue layer is thinner. -The​ dermal-epidermal junction is flattened. -There are less active melanocytes.

-There are less active melanocytes. Rationale-As the skin​ ages, it loses a number of active melanocytes in the epidermis. This increases susceptibility to skin damage from sun exposure. A thinner subcutaneous tissue layer increases the risk of hypothermia and pressure ulcers. A flattened​ dermal-epidermal junction increases the risk for skin​ tears, purpura, and pressure ulcers. Less eccrine and apocrine activity can cause dry skin and reduce perspiration.

During a home​ visit, the nurse suspects that a client with an alteration in skin integrity requires additional information about the disorder. Which behaviors did the nurse observe to come to this​ conclusion? (Select all that apply) -Applied moisturizer after washing hands -Used daughter​'s brush to fix hair -Applied a bandage over paper cut before preparing food -Kept wound on left forearm open to air -Washed hands 4 times in 1 hour

-Used daughter​'s brush to fix hair -Kept wound on left forearm open to air -Washed hands 4 times in 1 hour Rationale Interventions to improve skin integrity include keeping the skin​ clean, dry, and moisturized and covering wounds. Additional teaching would be needed because washing the hands 4 times in 1 hour would be​ over-cleansing of the skin. Wounds should be​ covered; the wound on the left forearm needs a bandage. Personal​ items, such as​ brushes, should not be shared to reduce the risk of parasite transfer.

A client is demonstrating signs of a skin infection. Which diagnostic test should the nurse expect to be prescribed for this​ client? -Wood lamp -Punch biopsy -Skin shaving -Patch test

-Wood lamp Rationale Tests used to identify a skin infection include the Wood lamp. A patch test is used to identify an allergy. Punch biopsy and skin shaving are approaches to obtain a skin biopsy.