Integumentary

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?

Undermining

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?

Separation of the proximal wound edges

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?

Stage III

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?

Low serum albumin level

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?

The patient takes oral hypoglycemic agents daily

Which information will the nurse include when teaching an older patient about skin care?

Use warm water and a moisturizing soap when bathing

The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate to ask at this time?

"Are you taking any medications?"

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?

"If the medication burns when I apply it, I will wipe it off."

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions?

"Your cheek area will be eroded and it will take several weeks to heal."

The nurse should plan to use a wet-to-dry dressing for which patient?

A patient who has a wound with purulent drainage and dry brown areas

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Elevate the ankle above heart level

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?

Prepare the patient for a skin biopsy

A patient with a systemic bacterial infection feels cold and has a shaking cold. Which assessment finding will the nurse expect next?

Rising body temperature

Which activities can the nurse workin in the outpatient clinic delegate to a licensed practical / vocational nurse (LPN / LVN) (select all that apply)?

- administer patch testing to a patient with allergic dermatitis - apply a sterile dressing after the health care provider excises a mole

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)?

- cool, wet cloths or compresses can be used to reduce itching - take cool or tepid bath several times daily to decrease itching - use of an over-the-counter (OTC) antihistamine can reduce scratching

The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)?

- erythema - actinic keratosis

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening?

38-year-old with a 7mm nevus on the face that has recently become darker

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient reports having no discomfort. Which action by the nurse is appropriate?

Check the patient's temperature again in 4 hours

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

Clean the infected areas with soap and water

A nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to the UAP?

Cleaning the skin with antimicrobial soap

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action?

Consult with the health care provider about the need for further diagnostic testing

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?

Cotton-tipped applicators

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?

Administer prescribed PRN hydrocodone 30 minutes before the change

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?

Ask about feelings of fatigue or malaise

The nurse notes darker skin pigmentation in the skin folds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action?

Ask the patient about a personal or family history of type 2 diabetes

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?

Ask the patient to describe the impact of psoriasis on quality of life

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next?

Assess the patient for evidence of liver disease

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?

Change the patient's position every 1 to 2 hours

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?

Check the lips and oral mucous membranes

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

Document the assessment

A patient is undergoing psoarlen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?

Have the patient use protective eyewear while receiving PUVA

A patient's 4 x 3 cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?

Hydrocolloid dressing

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?

Incisional biopsy

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority?

Maintaining the patient's blood glucose within a normal range

A 35-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?

Method of contraception used by the patient

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?

Minimizing sun exposure reduces risk for future BCC

A patient with an open leg lesion has a white blood cell (WBC) wound of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first?

Obtain cultures of the wound

A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

Papular, wheal-like lesions with white deposits on the hair shaft

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?

Petechiae on the chest and abdomen

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding?

Press firmly on the lesion

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse?

Reports a history of allergic rashes

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

Surgical excision

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions?

Symmetric

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first?

Talk with the patient alone and ask about the bruising

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?

Teach the use of cold packs to reduce bruising and swelling

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?

The family member dries the wound using a hair dryer on a low setting

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?

The new nurse cleans the ulcer with half-strength peroxide

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?

The patient applies a thick layer of the cream to the affected skin

After receiving a change-of-shift report, which patient should the nurse assess first?

The patient receiving chemotherapy who has a temperature of 102° F

The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin?

The patient recently had an intrauterine device removed

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

The patient uses a tanning booth weekly

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

The patient uses bacitracin-neomycin polymyxin on minor abrasions

The nurse could delegate care of which patient to a licensed practical / vocational nurse (LPN / LVN)?

The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

The nurse assesses a patient who has just arrived in the post anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?

The skin around the incision is pale and cold when palpated

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?

Thickening of the skin around the ankles

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?

Thinning of the affected skin

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

Try to stay out of the direct sun between the hours of 10 AM and 2 PM

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?

Use a sunscreen with a high SPF when exposed to the sun

What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?

Wash hands and properly dispose of soiled dressings