Chapter 49 : Management of Clients with Integumentary Disorders

When teaching a client with intermaxillary wiring, the nurse would instruct the client to avoid a. carbonated beverages. b. thick drinks. c. using a water irrigation device. d. vitamin supplements.

ANS: A Alcoholic and carbonated beverages should be avoided because they can cause nausea and create fizz and foam in the back of the throat, leading to airway problems. DIF: Comprehension/Understanding REF: p. 1236 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

When caring for a client after a chemical peel procedure to the face, the nurse would a. apply skin moisturizer. b. cleanse the client's face with an astringent. c. maintain the client in a head-down position. d. use abrasive cleaning agents.

ANS: A Care after chemical peel includes application of skin moisturizers, gentle cleansing, use of sunscreen, and avoidance of abrasive agents. Abrasives and astringents would dry and damage the fragile skin. The head-down position would encourage edema formation. DIF: Application/Applying REF: p. 1229 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

In the care of a client diagnosed with cutaneous T-cell lymphoma, the nurse's priority focus would be a. control of pruritus. b. pain management. c. prevention of metastasis. d. removal of the tumors.

ANS: A Control of pruritus is essential at all stages of lymphoma and is accomplished by rehydration of the skin, various dry skin therapies, topical corticosteroids, and PUVA therapy. DIF: Application/Applying REF: p. 1225 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

To help decrease the threat of a melanoma in a client at risk, the nurse would suggest that the client's diet should include a. fish oil capsules. b. lemon grass tea. c. oatmeal. d. red meat.

ANS: A Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma. DIF: Comprehension/Understanding REF: p. 1224 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

The physician ordered colloidal oatmeal baths followed by application of an occlusive ointment for a client with pruritus. The nurse's teaching plan would include explaining the need to a. apply the ointment to damp skin. b. bathe several times a day. c. soak for at least 30 minutes. d. use hot water in the bath.

ANS: A Immediate application of the occlusive substance to the damp skin is the most important detail, because if the skin is not occluded within 3 to 5 minutes, evaporation will begin to occur. DIF: Comprehension/Understanding REF: p. 1199 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

The nurse working with a UAP can delegate all of the following activities related to care of the client with a pressure ulcer except a. assessing the client's skin using a standardized tool. b. turning and repositioning the client according to a schedule. c. keeping the client's skin clean and dry. d. reporting any red areas that do not disappear after pressure relief.

ANS: A Options b, c, and d are all activities that can be delegated to the UAP. Assessment remains the responsibility of the professional nurse. DIF: Application/Applying REF: p. 1217 OBJ: Intervention MSC: Safe, Effective Care Environment Management of Care-Delegation

A nurse would instruct a client who experienced widespread first-degree sunburn to a. apply a water-based emollient after bathing. b. avoid the use of aspirin or ibuprofen. c. soak in cold baths for 20 minutes at a time. d. use over-the-counter local anesthetics.

ANS: A Tepid tap water baths are indicated for large sunburned areas. After a bath or soak, the client should apply water-based emollients. Over-the-counter remedies containing local anesthetics, such as benzocaine, dibucaine (Nupercaine), and lidocaine (Xylocaine), should be avoided because they are rarely effective and can induce contact sensitivity. A prostaglandin inhibitor such as aspirin may be used to reduce the erythema and inflammation in adults. DIF: Comprehension/Understanding REF: p. 1218 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

Before initiation of photochemotherapy (PUVA), the nurse instructs a client suspected of having lupus erythematosus about the diagnostic study that will be performed first, which is a(n) a. antinuclear antibody test. b. chest x-ray study. c. complete blood cell count. d. platelet count.

ANS: A The skin changes of clients with lupus erythematosus are aggravated by sun exposure, so photochemotherapy is contraindicated. Before therapy is initiated, an ANA test should rule out this condition when suspected. DIF: Comprehension/Understanding REF: p. 1206 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

Activities related to skin care the registered nurse can delegate to an unlicensed assistive personnel (UAP) include which of the following? (Select all that apply.) a. Applying over-the-counter lotions to skin that is not broken b. Assisting the client with frequent turning to prevent pressure ulcers c. Covering the client who complains of being cold with more blankets d. Placing a sterile gauze pad over broken skin to contain drainage e. Treating a new rash with topical antihistamines if ordered

ANS: A, B, C, D All the above options can be delegated to a UAP except option e. Prescription medications need to be applied by the registered nurse. The nurse needs to investigate a new rash for the possibility of an allergic reaction. DIF: Application/Applying REF: p. 1209 OBJ: Intervention MSC: Safe, Effective Care Environment Management of Care-Delegation

The nurse would counsel a client with eczema that the condition that might preclude the use of PUVA, or at least would require extra precautions, is a. age over 60. b. cataracts in development. c. long-term cortisone therapy. d. presence of open lesions.

ANS: B A history of cataract formation is a potential contraindication for PUVA. Clients who exhibit cataract formation need extra eye protection and more frequent ophthalmologic exams. DIF: Comprehension/Understanding REF: p. 1206 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

When providing topical treatment of lesions for a client with intertrigo, the nurse would avoid the use of a. Burrow's solution. b. cornstarch. c. talc-containing powder. d. topical steroids.

ANS: B Cornstarch should never be used because it encourages Candida albicans overgrowth. Burrow's solution (an antiseptic), talc-containing powders, and topical steroids are all possible treatments. DIF: Application/Applying REF: p. 1205 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

When caring for a client after rhytidectomy, the nurse notes that the left side of the client's face is drooping. The nurse would a. apply cold compresses. b. call the surgeon immediately. c. perform a neurosensory assessment. d. raise the head of the bed.

ANS: B One complication of the face lift is hematoma formation, often first manifested by facial asymmetry associated with pain on tightness on the affected side of the face. Hematomas can cause tissue necrosis and must be surgically removed before they cause damage. Cold compresses are useful for routine postoperative swelling and bleeding. The client should already be in Fowler position to minimize edema. A neurosensory assessment might be needed if a neurologic event is suspected. But the most common cause of this manifestation is hematoma, so the nurse should notify the surgeon. DIF: Application/Applying REF: p. 1231 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

Nursing care for a client with atopic dermatitis would focus primarily on a. decreasing pain. b. decreasing pruritus. c. preventing infection. d. promoting drying of lesions.

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring. DIF: Application/Applying REF: p. 1202 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

A client is expressing great disappointment that the plastic surgery did not turn out as well as expected. The client is distressed over visible scarring and lingering edema. The most appropriate nursing diagnosis for this client is a. Altered Coping b. Disturbed Body Image c. Fear d. Situational Low Self Esteem

ANS: B The most appropriate diagnosis is Disturbed Body Image since the client is complaining about the way his/her body looks postoperatively. If the client made negative comments about him/herself, the diagnosis would be Situational Low Self-Esteem. The client made no comments that would lead the nurse to choose either of the other two options. DIF: Analysis/Analyzing REF: p. 1230 OBJ: Diagnosis MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

After abdominoplasty, the nurse would place the client in the a. low-Fowler position. b. mid-Fowler position with knees bent. c. side-lying position. d. supine position with knees bent.

ANS: B The post-abdominoplasty client needs to lie in a contouring position (i.e., mid-Fowler position with knees bent) when in bed to decrease tension on the suture lines. DIF: Application/Applying REF: p. 1232 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

After blepharoplasty the client complains of itching of the eyes. The nurse would a. administer prescribed analgesia. b. apply cold wet dressings. c. irrigate the eyes with normal saline. d. notify the physician immediately.

ANS: B The post-blepharoplasty client may experience an itching sensation, similar to having dry eyes, because of slight corneal swelling. This can be relieved with cold wet dressings. DIF: Application/Applying REF: p. 1231 OBJ: Intervention MSC: Physiological Integrity Basic Care and Comfort-Non-Pharmacological Comfort Measures

In teaching a client about sun protection, the nurse would make an accurate suggestion with the statement a. "Sitting in the shade will protect you from sun exposure." b. "Use sunscreen, even on overcast days." c. "Use a sunscreen with the lowest SPF number." d. "Wear light-colored, loosely woven clothes."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. DIF: Comprehension/Understanding REF: Client Education Guide, Evolve site OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

Methotrexate is prescribed for a female client with psoriasis. When teaching the client about this medication, the nurse would explain that the client should avoid a. aged cheese. b. alcohol. c. birth control pills. d. milk products.

ANS: B To prevent liver damage, the client should avoid alcohol while taking methotrexate. Effective birth control is needed during treatment and for 3 months following completion of treatment. Milk products and aged cheese do not have interactions with this drug. DIF: Comprehension/Understanding REF: p. 1207 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

The nurse would reinforce to a client who is about to undergo liposuction for removal of excess fatty tissue that a. bed rest is required for 24 hours after suction lipectomy. b. final results may take up to 6 months to appear. c. only small amounts of tissue can be removed at one time. d. the client cannot receive analgesics after liposuction for several days.

ANS: B Usually up to 6 months is required for the final results of liposuction to be apparent, after edema subsides and subcutaneous tissue heals. Clients need to be aware of this so their expectations are not unrealistically high preoperatively. Clients gradually resume normal activities, although it may take up to 6 weeks before the client can engage in strenuous activity. Large amounts of fat can be removed, but the nurse must assess the client for hypovolemia. Oral analgesics are effective for pain. DIF: Application/Applying REF: pp. 1231-1232 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

A client had a nodule removed from his face that was diagnosed as basal cell carcinoma. In teaching this client, the nurse should include information on the need for future a. chemotherapy. b. frequent examinations. c. further assessment. d. radiation therapy.

ANS: B Clients who have had one basal cell carcinoma are at greater risk of developing others. Recurrences of previously treated basal cell carcinomas are also possible but more unusual. The possible recurrence generally is within the first 2 years after removal or therapy. DIF: Comprehension/Understanding REF: p. 1221 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Screening

The nurse would explain to a client that effective treatments for severe pruritus include (Select all that apply) a. oral corticosteroids. b. sealing emollients. c. tricyclic antidepressants. d. topical antihistamines. e. topical corticosteroids.

ANS: B, C Sealing emollients, applied immediately after a warm bath or soak, can be used with or without other topical medications. Tricyclic antidepressants can be used as they have a high binding capacity for H1 receptors and are especially useful in clients who would benefit from both the antidepressant and the antihistaminic effect. DIF: Comprehension/Understanding REF: pp. 1199-1200 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

Oral antiviral therapy is prescribed for a client with herpes zoster. The nurse would explain to the client that the medication is used to decrease (Select all that apply) a. itching. b. pain. c. postherpetic neuralgia. d. recurrence. e. spreading.

ANS: B, C When antivirals are started early in the disease, they can reduce pain and accelerate healing. They also seem to have a role in reducing the incidence of postherpetic neuralgia. Pain relief can also be obtained through analgesics and sedatives. DIF: Comprehension/Understanding REF: p. 1228 OBJ: Intervention MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

A client is returning to the nursing unit after an intermaxillary wiring to treat a facial fracture. What equipment is vital for the nurse to have at the bedside? (Select all that apply) a. Scale b. Suction set-up c. Thermometer d. Wire cutters

ANS: B, D Airway problems can lead to life-threatening situations for the client whose jaws are wired shut. Suction equipment must be readily available. If the client has an airway problem that cannot be cleared with suctioning, the nurse must cut the wires holding the jaw together. A thermometer is also needed shortly after the client returns to the nursing unit, but is not the priority over equipment to protect the airway. DIF: Application/Applying REF: p. 1236 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

Before plastic surgery, the nurse would help the client develop (Select all that apply) a. a good body image. b. a positive attitude. c. plans for payment. d. realistic expectations. e. satisfactory motivation.

ANS: B, D Preoperative teaching includes helping the client develop realistic postoperative expectations. Working with clients to bolster their body image is also important. DIF: Application/Applying REF: pp. 1228, 1230 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

The nurse would record the assessment of a nonblanching reddened area on an older client's sacrum as a. atopic dermatitis. b. intertrigo. c. stage 1 pressure ulcer. d. xerotic eczema.

ANS: C A reddened area that cannot be blanched, especially if it is on a bony prominence, is indicative of a stage 1 ulcer. Precautions should be taken at this point so that the ulcer does not progress. DIF: Analysis/Analyzing REF: p. 1210 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

A client asks about the nature of the underlying problem in skin that leads to the development of atopic dermatitis. The nurse's response would include that the problem is caused by a. a decrease in natural oils. b. decreased resistance to skin infections. c. decreased water content. d. increased sensitivity to histamines.

ANS: C Compared with normal skin, the dry skin of atopic dermatitis has a reduced water-binding capacity, a higher transepidermal water loss, and decreased water content. DIF: Comprehension/Understanding REF: p. 1201 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

The client is to apply topical 5-fluorouracil to a lesion diagnosed as actinic keratosis. The nurse would explain that the client should expect the skin to develop a. desquamation. b. dryness. c. erosion and necrosis. d. itching.

ANS: C Medication should be continued until the inflammatory response reaches the erosion, necrosis, and ulceration stage, at which time the medication should be stopped. DIF: Comprehension/Understanding REF: p. 1219 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

Discharge teaching for a client following rhytidectomy would include the instruction to a. sleep in the prone position only. b. practice coughing and deep breathing. c. maintain a liquid diet for 1 week. d. exercise the facial muscles daily.

ANS: C Postoperative instructions are to sleep with the head of bed elevated, minimize talking and chewing, control hypertension, and avoid coughing. DIF: Comprehension/Understanding REF: p. 1231 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

A nurse is working with a client suffering from chronic pruritus. The client is angry and frustrated. The nurse should incorporate actions into the care plan that acknowledge a. multiple treatments may be tried before finding one that works. b. the lack of any effective treatments for pruritus. c. the major impact pruritus has on quality of life. d. that pruritus is very expensive to treat.

ANS: C Pruritus is challenging because of its common occurrence, detrimental effect on skin health, and the major effect it may have on quality of life. DIF: Analysis/Analyzing REF: p. 1199 OBJ: Intervention MSC: Psychosocial Integrity Psychosocial Adaptation-Quality of Life

The statement by a client with psoriasis vulgaris that would indicate to the nurse the need for further teaching regarding the client's illness is a. "I could develop arthritis because of this disease." b. "I will always have psoriasis." c. "Psoriasis is caused by an infection." d. "Stress can cause psoriasis to worsen."

ANS: C Psoriasis vulgaris is a chronic, recurrent, erythematous, inflammatory disorder involving keratin synthesis. It is a genetic systemic disease with an immunologic basis. The cause of psoriasis vulgaris is unknown. Anxiety and stress often precede flare-ups. Up to one third of clients with moderate to severe psoriasis vulgaris develop psoriatic arthritis. DIF: Evaluation/Evaluating REF: p. 1205 OBJ: Evaluation MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

A nurse is caring for a client who had a musculocutaneous flap reconstruction. The nurse assesses the flap to be cool with dark dermal blood on lancing. The most appropriate action by the nurse is to a. document the findings and continue care. b. elevate the affected body part if possible. c. notify the surgeon immediately. d. rewrap the pressure dressing.

ANS: C The major concern with flap reconstruction is establishing and/or maintaining the blood flow to the flap. A cool, pale flap with decreased capillary refill, or dark dermal blood on lancing, indicate perfusion problems and the surgeon should be notified at once. The body part should already be elevated if possible unless that interferes with arterial flow. DIF: Application/Applying REF: p. 1234 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I have read there are now vaccines to protect you from getting a melanoma." The nurse's most helpful response would be a. "No, there is no vaccination for melanoma." b. "The vaccines were so ineffective they were withdrawn." c. "Vaccines are being developed against melanoma." d. "Yes the vaccine is available, but it is very expensive."

ANS: C Vaccines are in the process of being developed against primary melanoma. There is no cure for metastatic melanoma. DIF: Comprehension/Understanding REF: p. 1223 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Immunizations

A nurse is working with a client who has a disfigured face and who is undergoing a series of reconstructive operations. The nurse has formulated the diagnosis: Disturbed Body Image related to perceived disfigurement as a primary problem. The least helpful intervention by the nurse would be to a. present reality in a kind and compassionate manner. b. refer the client to a licensed aesthetician to help with makeup. c. say "I know how you feel" while sitting with the client. d. tell the client s/he has to look in a mirror to get used to the facial appearance.

ANS: C This statement is a communication barrier. Better statements include "You seem depressed" and "You are angry." These statements provide openings for communication. DIF: Application/Applying REF: p. 1230 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Communication

To prevent pressure ulcers in a frail elderly client, the nurse would (Select all that apply) a. bathe and dry the skin vigorously to stimulate circulation. b. keep the head of the bed elevated 30 degrees. c. offer nutritional supplements and frequent snacks. d. turn the client at least every 2 hours.

ANS: C, D Clients should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the client must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of doughnuts, elevated head of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline. DIF: Application/Applying REF: pp. 1209, 1215, 1224 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

A client is to have a basal cell carcinoma removed with Mohs' surgery. During preoperative teaching, it would be important for the nurse to explain that a. liquid nitrogen will be applied to the lesion. b. no dressing will be necessary. c. scarring is rare. d. the procedure may be long.

ANS: D Mohs' technique involves a series of excisions. Careful microscopic tissue assessment "maps" the presence or absence of malignant cells within each specimen. The procedure may be lengthy. DIF: Comprehension/Understanding REF: p. 1223 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

A client has severe cellulitis on the arm. The nurse would anticipate orders to administer medications to eradicate a. Candida albicans. b. group A beta-hemolytic streptococci. c. Staphylococcus aureus. d. Streptococcus pyogenes.

ANS: D Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. DIF: Analysis/Analyzing REF: p. 1225 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

The nursing care for a client after rhinoplasty would include a. administering aspirin to decrease inflammation. b. changing nasal packing daily to prevent infection. c. maintaining the client flat in bed to reduce edema. d. observing for excessive swallowing to assess for bleeding.

ANS: D Postoperatively, the nurse should assess for bleeding. While the client is sleepy from the anesthetic, excessive swallowing may be the only indication of bleeding.

Before a client has blepharoplasty, the nurse would assess the client for a. ability to close eyes completely. b. extraocular movement in each eye. c. facial symmetry and muscle strength. d. near and distant vision in each eye.

ANS: D Preoperative near and distant vision in each eye is assessed by asking the client to read from a book and from something in the distance while one eye is covered. These baseline data are critical to assess postoperative visual changes. DIF: Application/Applying REF: p. 1231 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration