Chapter 52: Nursing Management: Patients With Dermatologic Problems

Which procedure done for skin cancer conserves the most amount of normal tissue?

Mohs micrographic surgery Explanation: Mohs micrographic surgery is the technique that is most accurate and that best conserves normal tissue. The procedure removes the tumor layer by layer. Electrosurgery, cryosurgery, and surgical excision do not conserve the amount of normal tissue.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?

Scabies Explanation: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

melanoma. Explanation: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated

A male patient is being treated in the hospital for the effects of a debilitating ischemic stroke that he experienced 2 weeks ago. The patient's plan of care identifies a risk of skin breakdown due to the cognitive, sensory, and motor effects of the stroke. What intervention should the nurse prioritize in an effort to reduce the patient's risk of pressure ulcers?

Ensure that the patient's heels are elevated off the surface of his bed. Explanation: Nursing interventions for prevention and management of pressure ulcers include turning and repositioning the patient every 1 to 2 hours when in bed. A pillow or commercial heel protector may be used to support the heels off the bed when the patient is supine. Seating the patient in a chair is an important part of rehabilitation and should not be avoided for the sole purpose of reducing the risk of pressure ulcers. Teaching the patient about the management of pressure ulcers is unlikely to reduce their incidence; this is especially true given the patient's profound functional losses.

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?

IV Explanation: 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 II involves a break in the skin that may drain. Stage I is an area of erythema that does not blanch with pressure.

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." Explanation: When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. What is the appropriate teaching by the nurse to prevent skin damage?

"Apply sunscreen even on overcast days." Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 4 p.m. — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn alone because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?

College dormitory Explanation: The nurse is correct to anticipate a potential scabies outbreak in a college dormitory. Outbreaks are common where large groups of people are confined or housed. Spread of scabies is from skin-to-skin contact. Although there are groups of people at the shopping mall, swimming pool, and gymnasium, typically, there is no personal contact.

Which of the following aggravates the condition caused by acne vulgaris?

Cosmetics Explanation: Acne vulgaris is aggravated by cosmetics. Any correlation with specific food items such as chocolate is more myth than fact. Sunlight does not aggravate the condition caused by acne vulgaris.

The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be another cause for this condition?

End-stage kidney disease Explanation: Systemic disorders associated with generalized pruritus include chronic kidney disease.

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied:

Every 3 to 4 hours for sustained effectiveness. Explanation: Lotions are frequently used to replenish lost skin oils or to relieve pruritus. They are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect because if left in place for a long period, they may crust and cake on the skin.

When caring for a client in a prenatal clinic who has history of acne vulgaris, which client medication would the nurse advise against?

Isotretinoin Explanation: The nurse is correct to screen for the acne medication, isotretinoin (Accutane). It is contraindicated for pregnant females or those who may become pregnant due to the potential of first trimester miscarriages and congenital malformations.

A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder?

Isotretinoin vitamin A compounds (i.e., retinoids) are used with dramatic results in patients with nodular cystic acne unresponsive to conventional therapy. One compound is isotretinoin, which is used for active inflammatory popular pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (epidermal desquamation), thereby unseating and expelling existing comedones.

Which assessment finding indicates an increased risk of skin cancer?

A deep sunburn Explanation: A deep sunburn is a risk factor for skin cancer. A dark mole or an irregular scar is a benign finding. White irregular patches are abnormal but aren't a risk for skin cancer.

The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do?

Administer analgesic pain medication. Explanation: The patient with painful and extensive lesions should be premedicated with analgesic agents before skin care is initiated.

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

Antiviral Explanation: Oral acyclovir (Zovirax), when taken within 48 hours of the appearance of symptoms, reduces their severity, and prevents the development of additional lesions. Corticosteroids, analgesics,, and antipyretics are not used for this purpose.

Which of the following uses the body's own digestive enzymes to break down necrotic tissues?

Autolytic debridement Explanation: Autolytic debridement is a process that uses the body's own digestive enzymes to break down necrotic tissue. Application of enzymatic debriding agents speeds the rate at which necrotic tissues is removed. A form of mechanical debridement is a wet to dry dressing, which removes necrotic tissue and absorbs small to large amounts of exudates.

Diagnosis of skin cancer is confirmed by which of the following diagnostic tests?

Biopsy Explanation: Skin cancer is diagnosed by visual inspection and confirmed by biopsy. Skin scarping and blood cultures are not used to confirm skin cancer.

The nurse is caring for a client who may have a lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff?

Nits are difficult to move from hair shafts. Explanation: Lice eggs, or nits, can be confused with dandruff. However, dandruff consists of fine, white particles of dead, dry scalp cells that can be easily picked from the hair. Nits, on the other hand, look like small, yellowish-white ovals and are quite firmly fixed to the hair shaft. The nurse is correct to use the difference of the nits being securely attached to the hair shaft as a guide to confirmation of lice infestation.

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. Explanation: 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.

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base. Explanation: The classic lesions of impetigo are honey-yellow crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.

A nurse assesses a client with dry, rough, scaly skin without lesions on the legs. The client reports itching in the affected area. What skin assessment would the nurse document?

Pruritus Explanation: Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Shingles presents with lesions. Candidiasis presents with reddened skin and is often found in the folds of skin. Seborrhea refers to dry, scaly patches usually located on the scalp.

Photochemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis Explanation: Photochemotherapy is used for severe, disabling psoriasis that does not respond to other methods of treatments.

A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse?

Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Explanation: Current evidence supports an autoimmune basis for psoriasis (Porth & Matfin, 2009). Periods of emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers. In this disease, the epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results.

A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse knows that the primary method of treatment in this type of cancer is what?

Surgical excision Explanation: 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, but it may be an intervention. Squamous cell carcinoma is an invasive carcinoma, metastasizing by the blood or lymphatic system. Chemotherapy would not be the treatment goal.

Which of the following is a local side effect of topical corticosteroids?

Telangiectasia Explanation: Inappropriate use of topical corticosteroids can result in local and systemic side effects. Local side effects may include skin atrophy and thinning, striae, and telangiectasia. Systemic side effects may include hyperglycemia and symptoms of Cushing's syndrome.

Which of the following information regarding the transmission of lice would the nurse identify as a myth?

The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.

The nurse is providing instruction to a client with acne. The nurse promotes avoidance of which food(s)? Select all that apply.

The nurse should promote avoidance of foods associated with flare-up of acne, particularly those high in refined sugars, including chocolate, cola, and ice cream.

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response?

Through the application of extreme cold, the tissue is destroyed. Explanation: Cryosurgery is the application of extreme cold to destroy tissue. The other statements are false.

Which term describes a fungal infection of the scalp?

Tinea capitis is a fungal infection of the scalp. Tinea corporis involves fungal infections of the body. Tinea cruris describes fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus?

Fexofenadine (Allegra) Explanation: Nonsedating antihistamine medications such as Allegra are more appropriate to relieve daytime pruritus. Benadryl or Atarax, when prescribed in a sedative dose at bedtime, may be beneficial in producing a restful and comfortable sleep. Ativan has sedating properties and is used as an antianxiety medication.

Which sedative medication is effective for treating pruritus?

Hydroxyzine Explanation: Hydroxyzine is a sedating medication effective in the treatment of pruritus. Benzoyl peroxide, fexofenadine, and tetracycline are not effective in treating pruritus.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?

Impetigo Explanation: Impetigo is seen at all ages but is particularly common among children living under poor hygienic conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin given off by a particular form of ivy.

Which infecting agent causes scabies?

Itch mite Explanation: Several skin disorders involve an infecting agent. Scabies is caused by Sarcoptes scabiei, an itch mite. Parasitic fungi cause dermatophytosis in skin, scalp, and nails. Shingles is caused by a reactivated virus.

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition?

Kaposi sarcoma Explanation: Kaposi sarcoma is a frequent comorbidity in clients with AIDS. With platelet disorders, the nurse observes ecchymoses (bruising) and purpura (bleeding into the skin). Urticaria (wheals or hives) is the manifestation of allergic reactions. A painless chancre or ulcerated lesion is a typical finding in the client with syphilis.

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

Private room Explanation: Herpes zoster, a highly contagious infection, is transmitted by direct contact with vesicular fluid or airborne droplets from the infected host's respiratory tract. Placing the client with a client diagnosed with pneumonia places that client at risk for contracting herpes zoster. An isolation room with negative airflow isn't necessary for the client with herpes zoster. The nurse should assign the client to a private room. The client could safely room with the client who already had chickenpox; however, visitors might be unnecessarily exposed.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A]) Explanation: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

The nurse is instructing the parents of a child with head lice. Which statement should the nurse include?

Use shampoo with piperonyl butoxide. Explanation: The nurse's instructions should include shampooing with piperonyl butoxide, washing clothes in hot water, and disinfecting brushes and combs with piperonyl butoxide shampoo.

A client is being treated for acne vulgaris. What contributes to follicular irritation?

overproduction of sebum Explanation: The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.

A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have?

psoriasis Explanation: Photochemotherapy is used to treat psoriasis.

A patient has developed a wound infection following a transmetatarsal foot amputation. The patient's wound has been producing copious amounts of exudate in recent days, necessitating several dressing changes each day. Which of the following wound care interventions may be indicated in the treatment of this patient's wound?

Negative pressure wound therapy Explanation: Negative pressure wound therapy involves attachment to subatmospheric pressure via evacuation tube connected to a computerized pump. As such, it is able to remove large amounts of exudate from the wound bed. Débridement, oxygen therapy and collagen dressings do not have the potential to evacuate large quantities of exudate from a wound bed.

A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario?

Nodular melanoma Explanation: A nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. A nodular melanoma invades directly into adjacent dermis (i.e., vertical growth) and therefore has a poorer prognosis.

A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis?

Preventing infection Explanation: The major cause of death from toxic epidermal necrolysis is from sepsis. Monitoring vital signs closely and noticing changes in respiratory, kidney, and gastrointestinal function may help the nurse to quickly detect the beginning of an infection. Strict asepsis is always maintained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are essential. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infections or infectious disease should not visit the patient until they are no longer a danger to the patient. The nurse is critical in identifying early signs and symptoms of infection and notifying the primary provider. Antibiotic agents are not generally begun until there is an indication for the use. Hemorrhage, renal failure, and liver failure are not the major causes of toxic epidermal necrolysis.

Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?

Tinea pedis Explanation: Tinea pedis is an infection which begins in the skin between the toes and spreads to the soles of the feet. Tinea corporis is a skin infection of the body. Tinea capitis invades the hair shaft below the scalp. Tinea cruris is a skin infection of the groin.

The nurse teaches the client who demonstrates herpes zoster (shingles) that

the infection results from reactivation of the chickenpox virus. Explanation: It is assumed that herpes zoster represents a reactivation of the latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to clients with herpes zoster. Some evidence shows that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified?

Wear rubber gloves when in contact with soaps. Explanation: The nurse should advise the client to wear rubber gloves when coming in contact with any substance such as soap or solvents. The client should avoid wool, synthetics, and other dense fibers. The client should use tepid bath water and should pat rather than rub the skin dry.

Which term refers most precisely to a localized skin infection of a single hair follicle?

Furuncle Explanation: Furuncles occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters. The patient is suspected of having herpes zoster. What should the nurse know about the distribution of lesions of herpes zoster?

Grouped vesicles in linear patches along a dermatome Explanation: 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.

Which drug is an oral retinoid used to treat acne?

Isotretinoin Explanation: Isotretinoin, an oral retinoid, is used in clients diagnosed with nodular cystic acne that does not respond to conventional therapy. Estrogen, tetracycline, and benzoyl peroxide are not oral retinoids.

A client has been diagnosed with melanoma. What treatment option can the nurse expect will be used?

Radical excision Explanation: The treatment of a melanoma involves radical excision of the tumor and adjacent tissues, followed by chemotherapy. Laser surgery and cryosurgery is not used in the treatment of melanoma. Radiation is used in some types of cancer.

Which of the following is also known as "jock itch"?

Tinea cruris Explanation: Tinea cruris is also known as "jock itch." Tinea corporis is ringworm affecting the body. Tinea pedis is "athlete's foot." Tinea unguium is a type of ringworm that affects the toenails.

A patient is complaining of severe itching that intensifies at night. The nurse decides to assess the skin using a magnifying glass and penlight to look for the "itch mite." What skin condition does the nurse anticipate finding?

Scabies Explanation: Scabies is an infestation of the skin by the itch mite Sarcoptes scabiei. The patient complains of severe itching caused by a delayed type of immunologic reaction to the mite or its fecal pellets. During examination, the patient is asked where the pruritus is most severe. A magnifying glass and a penlight are held at an oblique angle to the skin while a search is made for the small, raised burrows created by the mites. One classic sign of scabies is the increased itching that occurs during the overnight hours, perhaps because the increased warmth of the skin has a stimulating effect on the parasite.

A client recently received lip and tongue piercings and subsequently developed a superinfection of candidiasis from the antibacterial mouthwash. What would the nurse recommend for this client?

Use an antifungal mouthwash or salt water. Explanation: The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the al mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse the mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.

A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:

isolate the client's bed linens until the client is no longer infectious. Explanation: To prevent the spread of scabies to other hospitalized clients, the nurse should isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client's condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn't require enteric precautions because the mites aren't found in feces.