NCSBN Lesson 8-I: Integumentary
The nurse in the urgent-care clinic is reviewing discharge instructions with a client who is prescribed doxycycline. Which statement by the client indicates understanding of the instructions? "I will apply sunscreen when outside to prevent a sunburn." "I will not wear my contact lenses while taking this medication." "I will carry glucose tablets with me in case I experience low blood sugar." "I will take this medication with an antacid to prevent an upset stomach."
1 Doxycycline is a tetracycline antibiotic. All tetracyclines can increase the sensitivity of the skin to ultraviolet light. The most common result is a sunburn. Clients on these types of medications should prevent sunburn by avoiding prolonged exposure to sunlight, wearing protective clothing and applying sunscreen to exposed skin while outdoors. This drug should be taken two hours before or after antacids, not with them. Hypoglycemia is not a common side effect of doxycycline. Wearing contact lenses is not contraindicated with this medication.
A client has herpes simplex I with visible cold sores on the lips. Which intervention is most important for the client to implement to prevent spreading the infection? 1. Avoid sharing towels. 2. Take antiviral medication as prescribed. 3. Do not scratch the affected area. 4. Wash hands frequently.
1 Sharing any items (towels, lipstick, toothbrush, utensils, cups, etc.) that may touch the mouth has the highest risk of spreading infection from one individual to another. Washing hands and not touching/scratching the affected area are proactive measures to prevent spreading the infection, but are not the priority. Taking antiviral medication as prescribed will promote healing.
Which information in a client's history would place them at an increased risk for skin cancer? Select all that apply. 1. The client's profession is fisherman. 2. The client is receiving an immunosuppressant drug. 3. The client has blond hair and green eyes. 4. The client is dark-skinned. 5. The client is 65-years-old.
1,2,3,5 A client with fair skin tone, blond or red hair and blue or green eyes are at increased risk for skin cancer. People who work outdoors (e.g., fishermen, farmers, bridge construction workers) are exposed to increased sunlight and ultraviolet light. Age risk factors are adults younger than 30 years and older than 50 years old. Risk of squamous cell skin carcinoma is increased for individuals receiving immunosuppressant drug therapy. Other risk factors include a previous history of sunburns, indoor tanning and family history of skin cancer.
The nurse is reviewing the medical record of a client with recurring, nonhealing venous stasis ulcers to the lower extremities. Which findings are most likely contributing to the nonhealing of the client's wounds? Select all that apply. 1. The client's body mass index (BMI) is 16.5. 2. The client is 74-years-old. 3. The client has a history of seasonal allergies. 4. The client smokes one pack of cigarettes per day. 5. The client has a history of benign prostatic hyperplasia. 6. The client's ethnicity is Asian American.
1,2,4 A number of factors can affect the skin's ability to heal once injured. Factors include chronic disease, age, presence of an infection (systemic or local), nutritional status, substance abuse and smoking. The client's medical record shows a number of factors that are affecting healing of the wounds for this client. The client is undernourished or malnourished (BMI less than 18), a smoker (nicotine causes vasoconstriction, increased coagulability and decreased oxygen delivery to tissues) and older (the aging process causes a decrease in collagen synthesis and epithelialization). The client's ethnicity and history of benign prostatic hyperplasia and allergies do not affect wound healing.
The home health nurse is reviewing the medical record of a client with recurring oral candidiasis. Which prescribed medication is most likely causing the client's condition? 1. Fluticasone (nasal spray) 2. Budesonide (inhaler) 3. Detemir insulin (injection) 4. Metformin (tab)
2 Budesonide is an inhaled glucocorticoid used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). The most common adverse effects are oropharyngeal (oral) candidiasis and dysphonia (hoarseness and difficulty speaking). Both effects result from local deposition of inhaled glucocorticoids. To minimize these effects, clients should rinse the mouth with water and gargle after each administration. Using a spacer device can help too. If candidiasis develops, it can be treated with an antifungal drug. The other medications are not likely to cause oral candidiasis.
A client presents at an urgent care center after burning their hand while cooking. The client's burn wound has an intact skin surface, with redness and blistering that covers their posterior hand. How should the nurse describe this wound when documenting in the client's medical record? 1. A full-thickness-wound 2. A partial-thickness wound 3. A superficial-thickness wound 4. A deep full-thickness wound
2 Burn wounds are classified as superficial-thickness, partial-thickness, full-thickness and deep full-thickness. The wound described here is a partial-thickness wound. It involves the entire epidermis and varying depths of the dermis. These wounds are red, moist and blanch when pressure is applied. When small vessels are damaged, they may leak plasma, causing blister formation. The correct answer is a partial-thickness wound.
A client has received instructions about the management of their chronic dermatitis. Which action by the client indicates an understanding of the instructions? 1. The client avoids use of antihistamines when a flare-up occurs. 2. The client avoids itching and scratching the affected area. 3. The client applies warm compresses to relieve itching. 4. The client requests to be prescribed oral corticosteroids.
2 Excessive itching can cause excoriation of the skin, potentially resulting in inflammation and infection. Cool compresses may cause vasoconstriction and decrease itching. Heat will exacerbate itching. Oral antihistamines are sometimes recommended to provide relief from itching, although they may cause drowsiness. Topical corticosteroids are also sometimes prescribed because they may numb the itch receptors.
The school nurse in an elementary school identifies an outbreak of head lice (pediculosis). Which interventions should the nurse implement to prevent the spread of the infestation? Select all that apply. 1. Notify the local health department of the outbreak. 2. Do not permit children to share bike helmets. 3. Instruct school parents, teachers and volunteers on how to detect lice and nits. 4. Reassure students that itching of the scalp is a common symptom. 5. Provide individual headsets or ear buds for each student.
2,3,4,5 Sharing items that touch the head, such as helmets, headsets, hats, combs, towels, etc., is a primary source of spreading pediculosis. Itching is a common and early sign of infestation and should be investigated immediately. Instructing parents and school personnel how to detect lice and nits will foster early recognition and treatment.Head lice is not a reportable disease.
The nurse in a long-term care facility is reviewing the medical record of a newly admitted client. Which of the following factors put the client at an increased risk for developing a pressure ulcer? Select all that apply. 1. The client has a history of exercise-induced asthma. 2. The client is receiving an immunosuppressant drug for rheumatoid arthritis. 3. The client has diabetes mellitus. 4. The client is alert and oriented to person, place, time and situation. 5. The client has a body mass index (BMI) of 30
2,3,5 Obesity or low body weight are risk factors for pressure ulcer injury. A BMI of 30 puts the client in the obese range, causing increased pressure while sitting or lying in bed. Diabetes mellitus may cause sensory altercations, which also is a risk factor. Immunosuppressant drugs may suppress or reduce the strength of the body's immune system. Exercise-induced asthma is not a direct risk factor and there is no indication the client is in respiratory distress. Clients who are confused may not report or sense pain or discomfort, which could decrease their ability to protect skin integrity, relieve pressure, maintain hygiene or report discomfort.
The nurse at the outpatient clinic is reviewing after-visit instructions with a client diagnosed with Staphylococcus aureus cellulitis to the right thigh area. Which statement by the client indicates understanding of the instructions? 1. "I will take all of the antibiotic pills until they are gone." 2. "This infection is a result of my diabetes and not preventable." 3. "I will apply an ice pack to the area to reduce the swelling." 4. "The infection is contagious and I need make sure to cover it completely."
2. Cellulitis is an inflammation of the subcutaneous tissue. Staphylococcus aureus and group A beta-hemolytic streptococci are common organisms responsible for causing bacterial skin infections such as cellulitis. It is important to complete the entire course of the prescribed antibiotic to prevent recurrence or drug-resistance. Cellulitis of this type is not typically contagious. Although being a diabetic predisposes the client for developing an infection in general, cellulitis tends to occur following a break in the skin that becomes infected. The client should apply moist heat, not cold, to the area.
The nurse in the dialysis center suspects that a client receiving hemodialysis is infected with scabies. Which transmission-based precautions should the nurse implement immediately? 1. Neutropenic precautions 2. Contact precautions 3. Bloodborne precautions 4. Airborne precautions
2. Contact precautions reduce the risk of transmission by direct or indirect contact. Indirect transmission involves contact with a contaminated object. Scabies is a parasitic skin infection that is transmitted by direct, physical contact with infected individuals or by sharing clothing or bedding with an infected individual. The other precautions are not appropriate for preventing the transmission of scabies. Bloodborne precautions are not transmission-based precautions. Those precautions fall under standard precautions, which are taken for every client when the possibility of exposure to blood and/or bodily fluids exists, regardless of the presence of a communicable infection
The caregiver of an older client with dementia asks the nurse to insert an indwelling urinary catheter to prevent incontinence-associated dermatitis. What should the nurse do next? 1. Obtain an order from the client's health care provider to insert the catheter. 2. Place an incontinence pad or adult diaper on the client. 3. Explain that the risk of a catheter-associated infection outweighs the benefits. 4. Hold the client's next dose of the prescribed diuretic.
3 Incontinence episodes are not a valid reason for inserting a urinary catheter. The risk of a catheter-associated urinary tract infection (CAUTI) is too great. The nurse should advocate for the client by educating the client's caregiver on better alternatives to prevent incontinence-associated dermatitis (IAD). Interventions to prevent incontinence and IAD include: setting up a toileting schedule for the client, offering to take the client to the bathroom after administration of diuretics, applying barrier cream to the perineum and changing soiled or wet undergarments and clothing promptly. The nurse should not hold the prescribed diuretic or place the client in an adult diaper since those actions can be construed as dignity issues and will not help prevent IAD.
The home health nurse is visiting an older adult client who recently moved to this community from a much colder climate. The nurse provides the client with instructions on how to prevent a heat stroke. Which statement by the client indicates that additional teaching is needed? 1. "I will take my daily jog early in the morning when it is cool outside." 2. "I will wear loose clothing and a hat when I walk my dog." 3. "I will not take my diuretic on days that I exercise." 4. "I will increase my fluid intake if I develop cramps when exercising."
3 It is important to exercise outside when the temperature is low as exposure to high temperature increases the likelihood of heat-induced injury. Increasing fluid intake before, during and after exercise will decrease the likelihood of muscle cramping. Loose clothing and a hat to provide shade will keep the body temperature down. While taking a medication such as a diuretic is a risk factor for non-exertional heat stroke, clients should always take medications as prescribed. If the client takes a diuretic, increasing fluid intake while exercising and being exposed to high temperatures will aid in maintaining adequate hydration status.
The nurse is caring for a client with a large wound. Which meal selection would be most appropriate to promote wound healing? 1. Chicken breast, potatoes and gelatin 2. Green salad, apple and ice cream 3. Turkey, spinach and orange juice 4. Pasta, broccoli and fat free milk
3 Protein, vitamins A and C and zinc promote wound healing and immune system functioning. Turkey is a poultry source rich in protein. Spinach is rich in vitamin A. Orange juice is a source high in vitamin C. Each food choice in this meal meets important requirements for the client with a large wound in the healing process. Gelatin does not contain any high source of nutrition. Pasta is high in carbohydrates. Apples are a good source of carbohydrates and fiber.
The nurse in a long-term care facility is observing a certified nursing assistant (CNA) change a soiled incontinence brief on a client with incontinence-associated dermatitis. Which action by the CNA would require the nurse to intervene? 1. Positions the client in a side-lying position. 2. Applies a thin layer of barrier cream to the perineum. 3. Cleanses the perineal area with toilet tissue. 4. Places an absorbent dressing pad over the wound.
3. Incontinence associated dermatitis (IAD) is a common perineal skin injury caused by excessive exposure to urine and stool. Perineal wound care for clients with IAD should include use of pre-moistened soft wipes, gentle cleansing with a mild soap and warm water, application of a thin layer of a skin-protectant barrier cream and application of an absorbent dressing or pad. The client should be positioned in a side-lying position to avoid pressure on the buttocks and perineum. Toilet tissue should be avoided because it can be abrasive to the injured perineal skin. The nurse should intervene and advise the CNA to use pre-moistened, soft wipes instead of toilet tissue.
The nurse in a long-term care facility is reviewing the plan of care for a client with quadriplegia. Which risk assessment scale should be included for this particular client? 1. The Hendrich scale 2. The Wong-Baker scale 3. The Braden scale 4. The Hamilton scale
3. A client who has paralysis of all four limbs (quadriplegia) is at risk of developing a pressure ulcer. A pressure ulcer is tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period of time. The Braden scale is used for predicting pressure ulcer risk, and should be included in this client's plan of care. The Hendrich scale is used for fall risk. The Wong-Baker scale uses visual faces to assess pain. The Hamilton scale is used to rate anxiety.
A client with eczematous dermatitis (eczema) of the hands asks the nurse how to treat the excoriation and scaling of the palmar surface of both hands. What is the best response by the nurse? "You should wear disposable gloves during the day." "You should take OTC diphenhydramine orally three times a day." "You should apply antibacterial cream to both hands." "You should soak both hands in lukewarm water twice a day."
4 Soaking the hands in lukewarm water, ideally with colloidal oatmeal added to it, is the best response. Soaking the hands will debride crust and scales, and soften the skin. Diphenhydramine is an antihistamine that can reduce itching, but will not help with the scaly, excoriated skin. In addition, the sedative effects of the medication can be dangerous and the drug should be taken only as needed, preferably at bedtime. Wearing gloves is not appropriate because it will trap moisture and warmth, most likely aggravating the eczema. An antibacterial cream is not indicated at this time, unless the client develops a localized infection.
A 15-year-old high school student comes to the school nurse's office and asks the nurse for permission to miss their physical education class. The nurse notes the presence of large, open comedones (blackheads), papules and pustules on the student's forehead, cheeks and chin. Which is the best response by the nurse? 1. "You cannot miss physical education class unless I have permission from your teacher." 2. "Why do you want to miss physical education class? It is a good opportunity to exercise." 3. "Please tell me more about your reason for not wanting to go to physical education class." 4. "Are you embarrassed about something? You really don't need to be."
Adolescence is a time of transitions and many adolescents will deal with issues that relate to self-esteem and body image in a body that is undergoing rapid changes. An individual's body image is based on the subjective interpretation of one's physical appearance. A disturbance in one's body image may occur with physical changes, such as severe facial acne that can cause comedones and inflammatory lesions on the face, neck and upper back. Nursing interventions for adolescents should focus on providing support and empathy to ease the difficult transitions they are undergoing. The best response by the nurse is an open-ended statement that invites the student to talk about the reason for not wanting to attend the physical education class. The other responses are nontherapeutic and indicate that the nurse is making assumptions about the student based on their physical appearance.
The nurse in a walk-in care clinic is reviewing the medical record of a client who is being treated for frostbite on their toes. Which medical condition most likely pterm-7laced the client at a higher risk for this type of injury? 1. Diabetes mellitus 2. Hyperthyroidism 3. Aortic stenosis 4. Systemic lupus erythematosus
Diabetic neuropathy is a complication of diabetes mellitus that is characterized by decreased sensation in the lower extremities. Clients with diabetic neuropathy are at risk for hypothermal tissue injuries (i.e., frostbite) because they may not feel the pain associated with cold exposure, making them unaware of soft tissue injury until it is severe. The diabetes most likely contributed to this client's frostbite injury. There is no immediate increased risk for hypothermal tissue injuries with the other conditions.
The home health nurse is caring for a 6-year-old client with cerebral palsy. The client's parent reports to the nurse that the child's older sibling was just diagnosed with impetigo. What priority intervention should the nurse add to the client's plan of care? 1. Start applying a topical anti-inflammatory cream to the client's skin to prevent the client from becoming infected. 2. Contact the client's pediatrician for a prescription for an oral antibiotic as a preventative measure. 3. Instruct the parent to provide the infected child with washcloths and towels separate from the client's. 4. Instruct the client's parent to keep the client isolated in their room until the sibling's infection has resolved.
Impetigo is a common and highly contagious, bacterial skin infection that mainly affects infants and children. Impetigo usually appears as red sores on the face, especially around a child's nose and mouth, and on hands and feet. The sores burst and develop honey-colored crusts. The priority nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications. Impetigo can easily spread and hand washing is mandatory before and after contact with an affected child. The infected child should be provided with washcloths and towels separate from those of other family members and the infected child's clothes should be changed daily and washed in hot water. A topical bactericidal ointment can be used if the client becomes infected too. An anti-inflammatory cream such as hydrocortisone will not prevent the client from becoming infected. Antibiotics should not be prescribed for prevention in this situation. Oral or parenteral antibiotics (penicillin) are reserved for severe cases of an actual infection. Keeping the client isolated is not necessary or appropriate in a home setting.
The nurse working in a dermatology office is reinforcing teaching with a client about skin cancer prevention. Which statement by the client requires follow up by the nurse? "I will use a tanning bed to get a tan so I avoid the harmful rays from the sun." Correct! "I plan to use sunless tanning creams to safely produce a tan." "I will avoid sun exposure between the hours of 11 am and 3 pm." "I will wear a wide-brimmed hat, sunglasses and long sleeves when I'm outside."
The major cause of skin cancer is overexposure to the sun's harmful ultraviolet (UV) rays. Sunscreen should be worn at all times when outdoors. It is also recommended to wear a wide-brimmed hat, long sleeves and sunglasses when outside. The sun's UV rays are the strongest between 11 am and 3 pm and should be avoided if possible. Sunless tanning creams can safely produce a tan coloring of the skin without harmful exposure to the sun. The nurse should follow up on the statement about using a tanning bed because tanning beds emit the same harmful UV rays as the sun and should be avoided.
A client presents with a burn that is painful, pale and waxy with large flat blisters. The client asks the nurse about the severity of the burn. What is the best response by the nurse? 1. The burn is a first degree burn. 2. The burn is a full-thickness burn. 3. The burn is similar to a sunbURN 4.The burn is a partial thickness burn.
The wound described is a deep partial thickness burn. A superficial, i.e., first-degree, burn or sunburn is bright red and moist, and might appear glistening with blister formation. A full-thickness burn involves all layers of the skin and may extend into the underlying tissue and is usually not painful.