Managements of Patients with Dermatologic Problems 14&15 E

A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions?

A) Cataract development is possible. Feedback: Patients using topical corticosteroid preparations repeatedly on the face and around the eyes should be aware that cataract development is possible. Weeping and glaucoma are less likely. There is no consequent risk of glaucoma.

A patients blistering disorder has resulted in the formation of multiple lesions in the patients mouth. What intervention should be included in the patients plan of care?

A) Provide chlorhexidine solution for rinsing the patients mouth. Feedback: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.

A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan?

A) Use caution when taking nonprescription medications./ Lifelong management is likely needed. Feedback: The patient should be cautioned about taking nonprescription medications because some may aggravate mild psoriasis. Psoriasis is not contagious. Many patients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessively frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?

A) Wash your face with water and gentle soap each morning and evening. Feedback: The nurse should inform the patient to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. Cleansing with rubbing alcohol is not recommended and all forms of manipulation should be avoided.

A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?

Assessment of the patients joints for pain and decreased range of motion Feedback: Asymmetric rheumatoid factornegative arthritis of multiple joints occurs in up to 30% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this residents plan of care?

Avoid using hot water during the patients baths. Feedback: If baths have been prescribed, the patient is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster?

Acyclovir (Zovirax) Feedback: Acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. There is evidence that infection is arrested if oral antiviral agents are administered within the first 24 hours. Prednisone is an anti-inflammatory agent used in a variety of skin disorders, but not in the treatment of herpes. Azanthioprine is an immunosuppressive agent used in the treatment of pemphigus. Triamcinolone is utilized in the treatment of psoriasis.

A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.

Affects people predominantly in the eastern half of Africa, Affects men more than women, Can progress to lymphadenopathic forms Feedback: Endemic (African) Kaposis sarcoma affects people predominantly in the eastern half of Africa, near the equator. Men are affected more often than women, and children can be affected as well. The disease may resemble classic KS or it may infiltrate and progress to lymphadenopathic forms.

A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected?

An area matching the color and texture of the skin at the surgical site is selected. Feedback: The site where the intact skin is harvested is called the donor site. Selection of the donor site is made to match the color and texture of skin at the surgical site and to leave as little scarring as possible.

A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?

Anticipate the need for, and administer, appropriate analgesic medications. Feedback: Nursing interventions after surgery for a malignant melanoma center on promoting comfort, because wide excision surgery may be necessary. Anticipating the need for and administering appropriate analgesic medications are important. Distraction techniques may be appropriate for some patients, but these are not a substitute for analgesia. Bed rest and a modified diet are not necessary.

A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?

Apply cornstarch to the patients skin after bathing to facilitate mobility. Feedback: After the patients skin is bathed, it is dried carefully and dusted liberally with nonirritating powder (e.g., cornstarch), which enables the patient to move about freely in bed. Open blisters should not normally be wiped and antibiotics are not applied to wound beds in the absence of a secondary infection. Water can safely be used to provide hygiene.

A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis sarcoma ?

Immunosuppression-related/ Iatrogenic Feedback: Immunosuppression-associated Kaposis sarcoma occurs in transplant recipients and people with AIDS. This form of KS is characterized by local skin lesions and disseminated visceral and mucocutaneous diseases. Classic Kaposis sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Endemic KS affects people predominantly in the eastern half of Africa. AIDS-related KS is seen in people with AIDS.

When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?

Impaired Skin Integrity Related to Scaly Lesions Feedback: An appropriate diagnosis for a patient with psoriasis would include Impaired Skin Integrity as it relates to scaly lesions. Psoriasis causes pain but does not normally affect the oral cavity. Similarly, tissue integrity is impaired, but not through the process of epidermal shedding. Psoriasis is not related to an increased risk for melanoma.

A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port- wine stains is what?

Laser treatment Feedback: Argon lasers are useful in treating cutaneous vascular lesions such as port-wine stains. Skin grafts, chemical face peels, and free flaps would not be used to remove a port-wine stain.

A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?

Benzoyl peroxide and erythromycin (Benzamycin) Feedback: Benzamycin gel is among the topical treatments available for acne. Zovirax is used in the treatment of herpes zoster as an oral antiviral agent. Benadryl is an oral antihistamine used in the treatment of pruritus. Intralesional injections of Kenalog have been utilized in the treatment of psoriasis.

A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?

Classic Kaposis sarcoma Feedback: Classic Kaposis sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Most patients have nodules or plaques on the lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal. Stasis ulcers do not create nodules. Bullous pemphigoid is characterized by blistering. Psoriasis characteristically presents with silvery plaques.

A nurse is caring for a client who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. The nurse knows that systemic treatment will most likely include which element?

Corticosteroid therapy Rationale: Treatment for bullous pemphigoid includes system corticosteroid therapy. This would not include skin biopsy as this is for diagnostics. Topical corticosteroids don't treat systemically. The goal of therapy is to respond to inflammation, not to treat infection.

A nurse is assessing a teenage patient with acne vulgaris. The patients mother states, I keep telling him that this is what happens when you eat as much chocolate as he does. What aspect of the pathophysiology of acne should inform the nurses response?

D) Diet is thought to play a minimal role in the development of acne. Feedback: Diet is not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms.

A nurse is providing care for a patient who has developed Kaposis sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?

D) Endothelial cells lining small blood vessels Feedback: Kaposis sarcoma (KS) is a malignancy of endothelial cells that line the small blood vessels. It does not originate in connective tissue, smooth muscle cells of the GI and respiratory tract, or in neural tissue.

When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply.

Epidermal necrosis, Increased metabolic needs, E) Possible gastrointestinal mucosal sloughing Feedback: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster?

Grouped vesicles in linear patches along a dermatome Feedback: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patients subsequent care?

Helping the patient identify and avoid the offending agent Feedback: A focus of care for patients with irritant contact dermatitis is identifying and avoiding the offending agent. Immunosuppressants are not used to treat eczema and wound care is not normally required, except in cases of open lesions. Poor hygiene has no correlation with contact dermatitis.

While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Malignant melanoma Feedback: A malignant melanoma presents itself as a superficial spreading melanoma which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. The lesion tends to be circular, with irregular outer portions. BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding. A dermatofibroma presents as a firm, dome-shaped papule or nodule that may be skin colored or pinkish-brown.

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?

Nits may have to be manually removed from the childs hair shafts. Feedback: Treatment for head lice should begin promptly and may require manual removal of nits following medicating shampoo. Head lice are not related to a lack of hygiene. Treatment is necessary because the condition will not likely resolve spontaneously within 1 week.

A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?

Perform hand hygiene. Feedback: The nurse and physician must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions?

Protect the graft from direct sunlight and temperature extremes. Feedback: Both the donor site and the grafted area must be protected from exposure to extremes in temperature, external trauma, and sunlight because these areas are sensitive, especially to thermal injuries. Antibiotic ointments are not typically prescribed and massage may damage these fragile sites. There is no need to protect the sites from all forms of moisture for the long term.

A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor?

Recent administration of new medications Feedback: In adults, TEN is usually triggered by a reaction to medications. Antibiotics, antiseizure agents, butazones, and sulfonamides are the most frequent medications implicated. TEN is unrelated to UV exposure, hygiene, or varicella infection.

A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond?

Remind the patient of the need to immobilize the graft to facilitate healing. Feedback: The nurse should instruct the patient to keep the affected part immobilized as much as possible in order to facilitate healing. Passive ROM exercises can be equally as damaging as active ROM.

A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.

Risk for Infection Related to Lesions, B) Impaired Skin Integrity Related to Epidermal Blisters C) Disturbed Body Image Related to Presence of Skin Lesions D) Acute Pain Related to Disruption in Skin Integrity Feedback: Blistering diseases disrupt skin integrity and are associated with pain and a risk for infection. Because of the visibility of blisters, body image is often affected. The patient faces a risk for hypothermia, not hyperthermia.

A nurse is caring for a client whose chemical injury has necessitated a skin graft to the client's left hand. Which statement is true regarding skin graft use?

Skin Is transferred from a distant site to the graft site. Rationale: Skin grafting is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site. Skin grafting can be used to repair almost any type of wound and is the most common form of reconstructive surgery.

A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?

Surgical excision Feedback: The primary goal of surgical management of squamous cell carcinoma is to remove the tumor entirely. Radiation therapy is reserved for older patients, because x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. Obtaining a biopsy would not be a goal of treatment; it may be an assessment. Chemotherapy and radiation therapy are generally reserved for patients who are not surgical candidates.

A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?

Teach the patient about self-care after treatment. Feedback: Because many skin cancers are removed by excision, patients are usually treated in outpatient surgical units. The role of the nurse is to teach the patient about prevention of skin cancer and about self-care after treatment. Assessing the patients risk for recurrent malignancy is primarily the role of the physician. Blistering diseases do not result from cancer or subsequent excision. Excision is not accompanied by radiotherapy.

A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this familys care?

Teaching about the importance of maintaining high standards of hygiene Feedback: Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective.

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?

Teaching participants to limit their sun exposure Feedback: Sun exposure is the best known and most common cause of BCC. BCC is not commonly linked to general health debilitation, family history, or radiation exposure.

A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?

Wide excision Feedback: Wide excision is the primary treatment for malignant melanoma, which removes the entire lesion and determines the level and staging. Chemotherapy may be used after the melanoma is excised. Immunotherapy is experimental and radiation therapy is palliative.

A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following?

Wrinkles near the lips and eyes Feedback: Chemical face peeling is especially useful for wrinkles at the upper and lower lip, forehead, and periorbital areas. Chemical face peeling does not remove acne scars, remove vascular lesions, or reshape the eyes.

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:

avoid placing body weight on the healing site. Rationale: The major goals of pressure injury treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the client teaching.

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?

D. IV Rationale: Stage III and IV pressure injuries are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure injuries must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?

Deficient Knowledge about Early Signs of Melanoma Feedback: The fact that the patients disease was not reported until an advanced stage suggests that the patient lacked knowledge about skin lesions. Excision does not result in chronic pain. Reconstructive surgery is not a certainty, and will not necessarily lead to depression. Anxiety is likely, but this may or may not be related to a lack of social support.

A nurse is preparing to assist a surgeon in a skin grafting procedure. What can a skin graft can be used for?

Denuded skin after burns. Rationale: Skin grafts are commonly used to repair surgical defects such as those that result from excision of skin tumors, to cover areas denuded of skin (e.g., burns), and to cover wounds in which insufficient skin is available to permit wound closure. They are also used when primary closure of the wound increases the risk of complications or when primary wound closure would interfere with function. It is not used for uncomplicated wound closure. Skin grafts are not used for infected wounds.

A patient has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this patients care, the nurse should include which of the following nursing diagnoses ?

Disturbed Body Image Related to Excess Sebum Production Feedback: Seborrhea causes highly visible manifestations that are likely to have a negative effect on the patients body image. Seborrhea does not normally affect fluid balance, thermoregulation, or tissue perfusion.

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?

Educating participants about the early signs and symptoms of skin cancer Feedback: The best hope of decreasing the incidence of skin cancer lies in educating patients about the early signs. There is a relationship between general health and skin cancer, but teaching individuals to identify the early signs and symptoms is more likely to benefit overall outcomes related to skin cancer. Teaching about treatment options is not likely to have a major effect on outcomes of the disease. Smoking is not among the major risk factors for skin cancer.

A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis?

Teaching the patient how to use and care for the prosthesis Feedback: The process of facial reconstruction is often slow and tedious. Because a persons facial appearance affects self-esteem so greatly, this type of reconstruction is often a very emotional experience for the patient. Reinforcement of the patients successful coping strategies improves self-esteem. If prosthetic devices are used, the patient is taught how to use and care for them to gain a sense of greater independence. This is an intervention that relates to Disturbed Body Image in these patients. None of the other listed interventions relates directly to the diagnosis of Disturbed Body Image.

A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patients wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response?

The major complication is when the blood supply fails and the tissue in the flap dies. Feedback: The major complication of a flap is necrosis of the pedicle or base as a result of failure of the blood supply. This is more likely than tearing of the pedicle and chronic pain and is more serious than loss of sensation.

A patient presents at the free clinic with a black, wart-like lesion on his face, stating, Ive done some research, and Im pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis ?

The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable. Feedback: Seborrheic keratoses are benign, wart like lesions of various sizes and colors, ranging from light tan to black. There is no harm in allowing these growths to remain because there is no medical significance to their presence.