prepu skin integrity
The nurse is caring for a client diagnosed with herpes zoster. Which statement by the client needs further clarification by the nurse?
"Once I get the infection, I cannot get it again."
Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.
"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."
The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for?
48-72 hours
A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?
Acyclovir
When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?
Administering systemic antibiotics as ordered
A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face?
Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.
A nurse is assessing a teenage client with acne vulgaris. The client's mother states, "I keep telling him that this is what happens when you eat as many french fries as he does." What aspect of the pathophysiology of acne should inform the nurse's response?
Diet is thought to play a minimal role in the development of acne.
Which of the following nonsedating antihistamines is appropriate for daytime pruritus?
Fexofenadine (Allegra)
What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?
Impaired Skin Integrity related to open wound
The nurse applies a moisture-retentive dressing to a patient's wound. She understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:
Provide autolytic debridement.
An extended care facility has been the site of a breakout of scabies in recent days. The staff at the facility recognize the need for an expedited, coordinated response to this outbreak. This response should include which of the following measures? Select all that apply.
Providing warm, soapy baths to affected residents Applying a topical scabicide to the skin of affected residents
A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?
Reassess the coccyx area for fading of the redness in 60 to 90 minutes.
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?
Secure the drain to the client's gown with a safety pin below the level of the wound.
What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply.
Skin atrophy Striae Telangiectasia
A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?
The wound is 3 × 5 cm, with yellow tissue covering the entire wound.
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
all family members need to be treated
A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?
antiviral
Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body?
autograft
The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?
college dorm
Pressure ulcers are caused by:
extrinsic factors
Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?
impetigo
In assessing a scar, you notice an overgrowth of tissue. It is best described as a
keloid
When a patient has been diagnosed with scabies, if the infection has spread, family members may complain of pruritus within which time frame?
one month
A nurse is examining a client's hair. What are the characteristics of a normal scalp? Select all that apply.
smooth, intact, free of lesions
The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea capitis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with ketoconazole or a selenium sulfide shampoo?
twice weekly
A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?
undermining
Dermatophytes (also called tinea) are parasitic fungi that invade the skin, scalp, and nails. How is a diagnosis made for this condition? Select all that apply.
visual examination Wood's light
A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.
"It may take longer for an older adult to heal." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing."
A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.
Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.
A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?
Albumin 2.8 mg/dL (28.0 g/L)
A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?
Grouped vesicles in linear patches along a dermatome
A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care?
Helping the client identify and avoid the offending agent
The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re-dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order.
Remove the soiled dressing wearing clean gloves. Clean the wound, wearing sterile gloves and using sterile supplies. Dry the surrounding tissue with gauze. Insert the culture swab deep into the wound, wearing clean gloves. Using a different pair of gloves, place a clean dressing on the wound.
A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.
The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response
A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?
Use clean technique instead of sterile technique if the wound is closed.
A patient's severe and widespread psoriasis has prompted her care provider to prescribe potent topical corticosteroids. When teaching this patient about her new medication regimen, the nurse should recognize that topical corticosteroids that are applied to large skin surfaces create a risk of:
adrenal suppression
A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues?
apply dressing with a binder
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 resident's plan of care?
avoid using hot water during baths
A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:
erythematous with raised papules.
A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?
fistula formation
A client with diabetes mellitus has impaired skin integrity due to an injury. Which skin disorder is the client likely to develop?
furuncle
The most important principle of psoriasis treatment is which of the following?
gentle removal of scales
A client 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?
hand hygiene
The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?
hemostasis phase
The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as
lichenification
A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?
lifelong management will likely be needed
A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?
period during which the wound undergoes changes and maturation
A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?
proliferation phase
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?
stage III
The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply.
the client who has a body mass index (BMI) of 34 the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the client who is experiencing an allergic reaction and is scratching the skin
Which of the following is also known as "jock itch"?
tinea cruris
Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?
tinea pedis
