SKIN AH2

The nurse is initiating a bladder training schedule for patient. What interventions can be provided for optimal success? (Select all that Apply)

- Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. - Give up to 3,000 mL of fluid daily - Teach bladder massage to increase intra-abdominal pressure.

A patient in rehabilitation has become dependent on family members assistance with self care. What can't he nurse do to encourage the patient to become independent? (Select all that apply)

- Motivate the patient to learn and accept responsibilities for self care. - Help the patient identify safe limits of independent activity. - Educate the patient in how to perform self care activities.

The nurse is assessing a patient with TEN. what assessment data would indicate that the patient may be progressing to keratoconjunctivitis? (Select all that apply)

- Pruritus of the eyes - Burning of the eyes - Dryness of the eyes

The nurse is developing a bowel training program for a patient. What education can the nurse proved for the patient that will increase the chance of success of the bowel program? (Select all that apply)

- Set daily defecation time that is within 15 minutes of the same time every day. - Have an adequate intake of fiber containing foods. - Have a fluid intake between 2 and 4 L per day.

What should the nurse assess or to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? (Select all that apply)

- Skin atrophy - Striae - Telangiectasia

Four major rehabilitative goals are:

1. Absence of contracture and deformity 2. Maintenance of muscle strength and joint mobility 3. Independent mobility 4. Increased activity tolerance 5. Prevention of Further disability

Two common musculoskeletal complications for patients who are in bed for prolonged periods are:

1. External rotation of the hip 2. Plantar flexion of the foot

List four collaborative problems for a patient with impaired physical mobility:

1. Impaired physical mobility 2. Activity intolerance 3. Risk for Injury 4. Risk for disuse syndrome

Five nursing diagnoses for patients with impaired physical mobility could be:

1. Impaired physical mobility 2. Activity intolerance 3. Risk for injury 4. Risk for douse syndrome 5. Impaired Walking 6. Impaired Wheelchair mobility 7. Impaired bed Mobility

Four factors that contribute to foot drop are:

1. Prolonged bed rest 2. Lack of exercise 3. Incorrect positioning in the bed 4. Weight of the bedding

Four microorganisms that contribute to infection in pressure ulcers are:

1. Streptococci, Staphylococci, Pseudomonoas aeruginosa, and escherichia coli

List eight specialty rehabilitation programs accredited by the Commission for the Accreditation of Rehabilitation Facilities:

1. Stroke recovery and traumatic brain injury 2. Spinal cord injury 3. Orthopedic 4. Cardiac 5. Pulmonary 6. Pediatric 7. Comprehensive pain management 8. Rehabilitation are specialty rehabilitation programs accredited by CARF

Name the three goals of rehabilitation.

1. To restore the patients ability to function independently or at a pre-illness or pre-injury level. 2. Maximize independence 3. Prevent secondary disability.

Name three complications commonly associated with prolonged or impaired physical immobility:

1. Weakened muscles 2. Joint contractures 3. Deformities

A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?

12 to 24 hours

The epidermis is almost completely replaced every

2 to 3 weeks

Serum albumin levels less than -------- increase the risk of pressure ulcers. Therefore, a protein intake of ------------- is recommended to promote ulcer healing.

3 g/dL; 1.25-1.5 g/Kg

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 to 72 hours

The nurse is caring for an adult patient with a norma body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient?

600 mL/day

What diet can't eh nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

Vitiligo

A localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches

TEN

A potentially fatal skin disorder

Permethrin

A prescription scabicide

Gel

A semisolid emulsion that becomes liquid when applied to the skin or scalp

Lidex

A topical corticosteroid with medium to high potency

8. A nurse assesses a client who has open lesions. Which action should the nurse take first? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the clients pain. d. Obtain vital signs.

ANS: A Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.

5. A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles

ANS: A Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.

12. A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

ANS: A Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paperthin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

2. A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. What do you do for a living? b. Are your nails professionally manicured? c. Do you have diabetes mellitus? d. Have you had a recent fungal infection?

ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

9. A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder? a. Clean hair and nails b. Poor eye contact c. Disheveled appearance d. Drapes a scarf over the face

ANS: A The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails; good eye contact; and being socially active. A disheveled appearance and draping a scarf over the face to hide the clients appearance demonstrate that the client may be having difficulty coping with his or her condition.

3. A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion. c. Examine the distribution of lesions over a section of the body. d. Monitor for edema or swelling of tissues. e. Focus your assessment on skin areas that itch.

ANS: A, B Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

2. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results

ANS: A, C, D Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the clients nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

7. A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with cornstarch e. Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help dbride crusts and scales. The nurse should implement cool, moist compresses and tepid baths with additives such as cornstarch. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

1. While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the clients oxygen saturation. c. Auscultate the clients lung fields for adventitious sounds. d. Palpate the clients bilateral radial and pedal pulses.

ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.

6. While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the clients pedal pulses bilaterally. c. Check for the presence of Homans sign. d. Assess the clients skin for adequate skin turgor.

ANS: B Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the clients limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow.

10. A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: B Pallor conjunctivae signifies anemia. The nurse should assess the clients hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this clients potential anemia.

11. During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

ANS: B??? Diffuse is used to describe lesions that are widespread. Serpiginous describes lesions with wavy borders. Clustered describes lesions grouped together. Linear describes lesions occurring in a straight line. Annular lesions are ringlike with raised borders, circinate lesions are circular, and circumscribed lesions have welldefined sharp borders. Coalesced describes lesions that merge with one another and appear confluent.

7. A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? a. I will consult the chaplain to provide you with spiritual support. b. You do not need to go to church; God is everywhere. c. Tell me more about your concerns related to your skin. d. Religious people are nonjudgmental and will accept you.

ANS: C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the clients skin changes are affecting the clients body image and encourage the client to express his or her feelings about a change in appearance. The other responses are not appropriate.

4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? a. This rash is probably due to fluid overload. b. I need to wash this daily with antibacterial soap. c. I can use powder to keep this area dry. d. I will schedule a mammogram as soon as I can.

ANS: C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. Are you using lotion on your skin? b. Do you have a family history of this? c. Do your arms itch? d. What medications are you taking?

ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

1. A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Societys hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.

Movement away front eh midline of the body

Abduction

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

Accutane

Movement toward the midline of the body

Adduction

The subcutaneous tissue, which is primarily composed of ___________ tissue, has a major role in ______________ regulation.

Adipose, temperature

The nurse is caring for a patient with extensive bullous lesions not eh trunk and back. Prior to initiating skin care, what is a priority for the nurse to do?

Administer analgesic pain medication

Famvir

An antiviral agent used to treat herpes zoster

Santyl

An enzymatic debriding agent

Scabies

An infestation caused by the itch mite

Keratin

An insoluble, fibrous protein that forms the outer layer of skin

Dermatosis

Any abnormal skin condition

The nurse is instructing the patient in how to apply a corticosteroid cream to lesions on the arm. What intervention can the nurse instruct the patient to do to increase the absorption of the medication?

Apply an occlusive dressing over the site after application

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.

Asymmetrical Change in size Itching Bleeding of a mole

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

Pyodermas

Bacterial skin infections

The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use?

Barthel Index

Two assessment scales that nurses can use to quantify a patient's risk for pressure ulcer formation are the:

Braden scale and the norton scales.

A patient has developed boil on the face and nurse observes the patient squeezing the boil. what does the nurse understand is a potential severe complication of this manipulation?

Brain abscess

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken with the presence of a blister

The nurse assesses a dark skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?

Carbon monoxide poisoning

Alkaline producing beverages such as-------------- promote bacterial growth in the urine and should be avoided for patients who suffer from incontinence.

Carbonated soft drinks, milk shakes, alcoholic drinks and citrus drinks

What is the rationale for asking the client whether he or she has noticed any new or changed moles?

Changes in existing moles or the appearance of new moles can indicate melanoma.

When inspecting the hair, what would the nurse note? (Select all that apply.)

Color Condition of hair shaft Hair shafts that are shiny

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that he heat is reduced?

Conduction

How do cytokines work?

Cytokines are proteins with mitogenic activity that release increased amounts of growth factors into a wound. This process stimulates cells growth and granulation of skin.

Skin needs to be exposed to sunlight to manufacture vitamin ________

D

Autolytic _________ is a process that uses the body's own digestive enzymes to break down necrotic tissue.

Debridement

Hypopigmentation

Decrease in the melanin of the skin, resulting in a loss of pigmentation

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the patient questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

Destruction of hair follicles located in the dermis layer

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

Document the findings in the client's record as normal

Beding of the foot toward the leg

Dorsiflexion

Cheilitis

Dry crackling skin at corners of the mouth

When assessing the skin of an older adult, what major age-related changes are seen in the skin?

Dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Cellular changes associated with aging include a thinking at the junction of the dermis and epidermis

The nurse should assess all possible causes of pruritus for a patient complaint of generalized pruritus. what does the nurse understand can be other causes for this condition?

End stage kidney disease

There are three layers of the skin:

Epidermis, dermis, and subcutaneous tissue

The initial sign of pressure is ----------------, which is caused by ---------------- -----------, unrelieved pressure results in ------------------ and -------------.

Erythema, Reactive Hyperemia, Tissue ischemia and anoxia

Eschar covering an ulcer should be removed surgically for what reason?

Eschar does not permit free drainage of the tissue

The patent is advised to apply a suspension type lotion to a dermatosis site. the nurse should advise the patient to apply the lotion how often to be effective?

Every 3 hours

Increasing the angle of a joint

Extension

The nurse is applying foam dressing to an exudative sacral decubitus ulcer. After application of the foam dressing, what is important that the nurse do?

Foam dressings are non adherent, thus the nurse must apply a secondary dressing to keep them in place.

___________________ is an important principle of psoriasis treatment

Gentle removal of the scales

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

Have you been eating large amounts of carotene-rich foods?

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes Zoster

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?

Hyperemia

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

The nurse should know that clubbing of the nails is usually a diagnostic sign of __________________

Hypoxia

Hyperpigmentation

Increase in the melanin of the skin, resulting in a increase in pigmentation

__________ is the leading cause of death in people with blistering diseases

Infection

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area

Movement that turns the sole of the foot inward

Inversion

Name the potential complications of Stevens Johnson Syndrome and toxic epidermal necrolysis:

Keratoconjuctivitis, sepsis, and multiple organ disfunction syndrome are potential complications of TENS and SJS.

Carbuncle

Localized skin infection involving hair follicles

Furuncle

Localized skin infection involving only 1 hair follicle

Liniments

Lotions with added oil to soften skin

Describe why moisture retentive dressings are efficient at removing exudate:

Moisture retentive dressing have high moisture vapor transmission rate. Some dressings even have reservoirs to hold excessive exudate

Tinea

Most common fungal infection of skin or scalp

A life threatening complication of a state IV pressure ulcer is:

Osteomyelitis

Xerosis

Overly dry skin

There are three types of wound dressings:

Passive, interactive, active

A patient is being treated for chronic venous stasis ulcers of the lower extremities. what medicating ors the nurse understand will increase peripheral blood flow by decreasing the viscosity of blood and assist with the healing of the ulcers?

Pentoxifylline (trental)

Petechia

Pinpoint red spots that appear on the skin as a result of blood leakage into the skin

The nurse is as siting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction.

The nurse is assessing a patient with a primary skin lesion called a macule. what does the nurse understand is a clinical example of this lesion?

Port wine stain

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures

List four major objectives of therapy for patient with dermatologic problems:

Prevent additional damage, prevent secondary infection, revise the inflammatory process, and relieve symptoms.

Comedone

Primary lesion of acne

Rotating the forearm so that the palm is down

Pronation

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Psoriasis

The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting not eh surface of the nail. What disorder is the finding indicative of?

Psoriasis

A patient is diagnosed with psoriasis after developing scales o 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 a overproduction of keratin.

When assessing a patent with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?

Purplish cutaneous lesions

Telangiectases

Red marks on the skin caused by distention of the superficial blood vessels

The nurse is assessing a patient for psoriatic lesions after treatment with a non steroidal cream. What type of lesion does the nurse know is characteristic of psoriasis?

Red, raised patch covered with silver scales

Two areas that are the most susceptible to the effects of shear and therefore pressure ulcer formation are the ------------ and the --------.

Sacrum; heels

Scabies is an infestation of the skin by the itch mite

Sarcoptes scabiei

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

Jaundice can first be observed by examining the ___________ and ____________

Sclera, mucous membranes

What position should be avoided when positioning a patient in bed in order to decrease the incidence of musculoskeletal complications?

Semi Fowlers

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum Albumin

Bullous impetigo, a deep seated infection characterized by large, fluid filled blisters, in caused by the bacteria

Staphlococcus aureus

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor int eh patient with a disability attempting to seek employment?

Substance abuse

The main secretory function of the skins performed by the _______________, which help regulate body temperature.

Sweat glands

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

Hirsutism

The condition of having excessive hair growth

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

Describe what function the hair of the skin serves.

The hair of the skin provides thermal insulation in mammals with hair or fur. This function is enhanced during cold or fright by piloerection, caused by contraction of the tiny erector muscles attached to the hair follicle.

The nurse has developed an evidence based pan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

The patient

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The patient may have been abused.

What is the function of the receptor endings of nerves in the skin?

The receptor endings of nerves in the skiing allow the body to constantly monitor the conditions of the immediate environment. They sense temperature, pain, light touch, and pressure.

The nurse is caring for patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull

Which of the following statements most accurately conveys an aspect of the anatomy and physiology of the skin?

The skin is composed of an epidermis, dermis, and subcutaneous tissue.

To maintain use, a joint should be moved through its range of motion at least --------- times a day.

Three

There are three types of therapy indicated for the treatment of psoriasis:

Topical, phototherapy, systemic

What is the most important focus area for the integumentary system?

UV radiation exposure

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

Under the breast

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

The nurse is fitting a patient for crutches that are required for an snake injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height?

Use the patients height and subtract 16 inches.

The nurse examines patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?

With initial patient contact

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis.

6. A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. "Wash your hands before touching the client." b. "Wear gloves when bathing the client." c. "Assess skin for breakdown during the bath." d. "Apply lotion to lesions while the skin is wet." e. "Use a damp cloth to scrub the lesions."

a. "Wash your hands before touching the client." b. "Wear gloves when bathing the client."

12. A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a. "You can use tap water instead of sterile saline to clean your wound." b. "If you don't clean the wound properly, you could end up in the hospital." c. "Sterile procedure is necessary to keep this wound from getting infected." d. "Good hand hygiene is the only thing that really matters with wound care."

a. "You can use tap water instead of sterile saline to clean your wound."

4. A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

a. Change the dressing every 6 hours.

9. A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a. Client admitted from a nursing home with furuncles and folliculitis b. Client with a leg cut and other trauma from a motorcycle crash c. Client with a rash noticed after participating in sporting events d. Client transferred from intensive care with an elevated white blood cell count

a. Client admitted from a nursing home with furuncles and folliculitis

1. A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a. Client with a left heel ulcer with slight necrosis - Whirlpool treatments b. Client with an eschar-covered sacral ulcer - Surgical débridement c. Client with a sunburn and erythema - Soaking in warm water for 20 minutes d. Client with urticaria - Wet-to-dry dressing changes every 6 hours e. Client with a sacral ulcer with purulent drainage - Transparent film dressing

a. Client with a left heel ulcer with slight necrosis - Whirlpool treatments b. Client with an eschar-covered sacral ulcer - Surgical débridement

7. A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with cornstarch e. Back rub with baby oil

a. Cool, moist compresses c. Heating pad

2. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

a. Place a small pillow between bony surfaces. d. Use a lift sheet to assist with re-positioning. f. Keep the client's heels off the bed surfaces.

11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

a. Place the client in a single room.

21. A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Wood's lamp examination d. Diascopy

a. Punch skin biopsy

18. A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a. Recent wound assessment, including size and appearance b. Insurance information for billing and coding purposes c. Complete health history and physical assessment findings d. Resources available to the client for wound care supplies

a. Recent wound assessment, including size and appearance

4. A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. c. Avoid whirlpool therapy. d. Use loose dressing on all wounds. e. Implement pressure-relieving devices.

a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. e. Implement pressure-relieving devices.

The most common skin condition in adolescents and young adults between the ages of 12 and 35 years is _________

acne

The term used to describe hair loss is __________

alopecia

Corticosteroids are widely used in treating dermatologic conditions to provide ___________ , _________________, and ____________.

anti-inflammatory, antipruritic, vasconstrictive

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast.

Pemphigus vulgaris is an ___________ disease in which the immunoglobulin (IgG) antibody is directed against a specific cell surface antigen in epidermal cells

autoimmune

5. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

b. "Have you been under a lot of stress lately?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

20. A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. "Do you have a bedpan at home?" b. "How are you coping with providing this care?" c. "What are you doing to prevent pediculosis?" d. "Are you sharing a bed with your husband?"

b. "How are you coping with providing this care?"

13. After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a. "At the next family reunion, I'm going to ask my relatives if they have psoriasis." b. "I have to make sure I keep my lesions covered, so I do not spread this to others." c. "I expect that these patches will get smaller when I lie out in the sun." d. "I should continue to use the cortisone ointment as the patches shrink and dry out."

b. "I have to make sure I keep my lesions covered, so I do not spread this to others."

6. After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a. "I can help him shift his position every hour when he sits in the chair." b. "If his tailbone is red and tender in the morning, I will massage it with baby oil." c. "Applying lotion to his arms and legs every evening will decrease dryness." d. "Drinking a nutritional supplement between meals will help maintain his weight."

b. "If his tailbone is red and tender in the morning, I will massage it with baby oil."

3. A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.

b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. e. Ensure that gloves are available in the room.

23. A nurse evaluates the following data in a client's chart: Admission Note Prescriptions Wound Care 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the provider and express concerns related to the wound treatment prescribed. c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

b. Contact the provider and express concerns related to the wound treatment prescribed.

7. After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Low-fat diet with whole grains and cereals and vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with nutritional supplements and fish oil capsules d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

b. High-protein diet with vitamins and mineral supplements

14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

b. Irregular blue mole with white specks on the lower leg

22. A nurse evaluates the following data in a client's chart: Admission Note Laboratory Results Wound Care Note 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer - 4 cm ´ 2 cm ´ 1.5 cm Based on this information, which action should the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the client's vital signs.

b. Request a dietary consult.

19. A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the client's hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

b. Shake the client's hand and introduce self.

16. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a. "Do you spend a great deal of time in the sun?" b. "Have you or any family members ever had skin cancer?" c. "Which method of contraception are you using?" d. "Do you drink alcoholic beverages?"

c. "Which method of contraception are you using?"

2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker

c. A 65-year-old with hemi-paralysis and incontinence

3. When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.

c. Apply a different pressure-relieving device.

15. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a. Administer it over 30 minutes using an IV pump. b. Give the client diphenhydramine (Benadryl) before the drug. c. Assess the IV site at least every 2 hours for thrombophlebitis. d. Ensure that the client has increased oral intake during therapy.

c. Assess the IV site at least every 2 hours for thrombophlebitis.

8. A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size

c. Client with a white blood cell count of 23,000/mm3

1. A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a. "Use lots of moisturizer several times a day to minimize dryness." b. "Take a cold shower instead of soaking in the bathtub." c. "Use antimicrobial soap to avoid infection of cracked skin." d. "After you bathe, put lotion on before your skin is totally dry."

d. "After you bathe, put lotion on before your skin is totally dry."

10. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a. "I'll apply cortisone cream to reduce the inflammation." b. "I'll apply a clean dressing after squeezing out the pus." c. "I'll keep my arm down at my side to prevent spread." d. "I'll cleanse the area prior to applying antibiotic cream."

d. "I'll cleanse the area prior to applying antibiotic cream."

5. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Place the client in bed and instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

d. Assess the right leg for pulses, skin color, and temperature.

17. A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Viral infection - Clindamycin (Cleocin) b. Bacterial infection - Acyclovir (Zovirax) c. Yeast infection - Linezolid (Zyvox) d. Fungal infection - Ketoconazole (Nizoral)

d. Fungal infection - Ketoconazole (Nizoral)

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

There are two types of skin glands

sebaceous, sweat

12. A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you dont clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.

ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.

9. A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a. Client admitted from a nursing home with furuncles and folliculitis b. Client with a leg cut and other trauma from a motorcycle crash c. Client with a rash noticed after participating in sporting events d. Client transferred from intensive care with an elevated white blood cell count

ANS: A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.

11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the clients airway. d. Apply gloves to minimize friction.

ANS: A The clients presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the clients infectious disorder.

18. A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a. Recent wound assessment, including size and appearance b. Insurance information for billing and coding purposes c. Complete health history and physical assessment findings d. Resources available to the client for wound care supplies

ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.

21. A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Woods lamp examination d. Diascopy

ANS: A This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.

4. A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

6. A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. Wash your hands before touching the client. b. Wear gloves when bathing the client. c. Assess skin for breakdown during the bath. d. Apply lotion to lesions while the skin is wet. e. Use a damp cloth to scrub the lesions.

ANS: A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the clients skin. The other statements are not appropriate for the care of open skin lesions.

1. A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a. Client with a left heel ulcer with slight necrosis Whirlpool treatments b. Client with an eschar-covered sacral ulcer Surgical dbridement c. Client with a sunburn and erythema Soaking in warm water for 20 minutes d. Client with urticaria Wet-to-dry dressing changes every 6 hours e. Client with a sacral ulcer with purulent drainage Transparent film dressing

ANS: A, B Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently remove the necrosis. A wound covered with eschar most likely needs surgical dbridement. Warm water would not be recommended for a client with erythema. A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers, respectively.

4. A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. c. Avoid whirlpool therapy. d. Use loose dressing on all wounds. e. Implement pressure-relieving devices.

ANS: A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin wont tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.

2. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the clients heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

23. A nurse evaluates the following data in a clients chart: Admission Note Prescriptions Wound Care 78-yearold male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuumassisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a. Assess the clients vital signs and initiate continuous telemetry monitoring. b. Contact the provider and express concerns related to the wound treatment prescribed. c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

ANS: B A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications. The health care provider needs this information quickly to plan other therapy for the clients wound. The nurse should contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

20. A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. Do you have a bedpan at home? b. How are you coping with providing this care? c. What are you doing to prevent pediculosis? d. Are you sharing a bed with your husband?

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wifes feelings and provide support for coping with changes. Asking about the clients toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregivers support and coping mechanisms and ability to continue to care for her husband.

19. A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the clients hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.

6. After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education? a. I can help him shift his position every hour when he sits in the chair. b. If his tailbone is red and tender in the morning, I will massage it with baby oil. c. Applying lotion to his arms and legs every evening will decrease dryness. d. Drinking a nutritional supplement between meals will help maintain his weight.

ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.

13. After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. At the next family reunion, Im going to ask my relatives if they have psoriasis. b. I have to make sure I keep my lesions covered, so I do not spread this to others. c. I expect that these patches will get smaller when I lie out in the sun. d. I should continue to use the cortisone ointment as the patches shrink and dry out.

ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

7. After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Low-fat diet with whole grains and cereals and vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with nutritional supplements and fish oil capsules d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

22. A nurse evaluates the following data in a clients chart: Admission Note Laboratory Results Wound Care Note 66-yearold male with a health history of a cerebral vascular accident and leftside paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer 4 cm 2 cm 1.5 cm Based on this information, which action should the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the clients vital signs.

ANS: B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided.

14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

3. A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.

ANS: B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.

5. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.) a. Have you eaten a large amount of chocolate lately? b. Have you been under a lot of stress lately? c. Have you recently used a public shower? d. Have you been out of the country recently? e. Have you recently had any other health problems? f. Have you changed any medications recently?

ANS: B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

8. A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size

ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.

2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker

ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.

3. When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.

ANS: C Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

16. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a. Do you spend a great deal of time in the sun? b. Have you or any family members ever had skin cancer? c. Which method of contraception are you using? d. Do you drink alcoholic beverages?

ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?

Peripheral cyanosis

15. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a. Administer it over 30 minutes using an IV pump. b. Give the client diphenhydramine (Benadryl) before the drug. c. Assess the IV site at least every 2 hours for thrombophlebitis. d. Ensure that the client has increased oral intake during therapy.

ANS: C Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to red man syndrome), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.

5. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Place the client in bed and instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

10. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching? a. Ill apply cortisone cream to reduce the inflammation. b. Ill apply a clean dressing after squeezing out the pus. c. Ill keep my arm down at my side to prevent spread. d. Ill cleanse the area prior to applying antibiotic cream.

ANS: D Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.

17. A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Viral infection Clindamycin (Cleocin) b. Bacterial infection Acyclovir (Zovirax) c. Yeast infection Linezolid (Zyvox) d. Fungal infection Ketoconazole (Nizoral)

ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

1. A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education? a. Use lots of moisturizer several times a day to minimize dryness. b. Take a cold shower instead of soaking in the bathtub. c. Use antimicrobial soap to avoid infection of cracked skin. d. After you bathe, put lotion on before your skin is totally dry.

ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.

The epidermis is composed of three types of cells:

Keratinocytes, Merkel cells, and Langerhans Cells

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when perfuming a skin assessment on this patient?

Jaundice

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?

Keloid

Describe how the production of melanin is controlled

Melanin is controlled by a hormone secreted fro the hypothalamus of the brain called melanocyte-stimulating hormone

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

Palmar surfaces

A patient is visiting the physician to dermic what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the client's is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm

___________, _____________ and _____________ are the major physical processes involved in loss of heat from the body to the environment.

Radiation, conduction, convection

Erythema

Redness of the skin caused by congestion of the capillaries

Melanin

The substance responsible for coloration of the skin

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures.

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism.

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

To assess an adult client's skin turgor, the nurse should

use two fingers to pinch the skin under the clavicle.