Chapter 24 Evolve/NCLEX
While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include? "Administration of local anesthetic agents may cause burning." "The biopsy results will be available within 2 hours of the procedure." "The dressing must remain in place for the first 48 hours." "Redness and swelling at the puncture site are expected."
"Administration of local anesthetic agents may cause burning." Local anesthetic agents may cause a burning sensation for the client. Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy, and may be an indication of infection.
An older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? "How does this make you feel?" "How is this affecting you?" "Wear a hat outside to stay warm." "You could wear a wig."
"How is this affecting you?" Asking the client how she is affected assesses the need for additional counseling. Although asking how the client feels assesses the psychosocial aspect of the problem, it does not direct further action for the nurse. Encouraging the client to wear a hat or a wig most likely is not what the client wants or needs to hear.
The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? "Every morning, I check the biopsy site for signs of infection." "I have been cleaning my face with soap and water." "My appetite is improving lately." "I have been working in my garden for several hours every day."
"I have been working in my garden for several hours every day." Basal cell carcinomas of the skin are associated with sun exposure. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens. The client should check the biopsy site daily for signs of infection. Cleaning the face with soap and water helps to prevent infection. It is normal for the client's appetite to improve.
The nurse is instructing a client on skin and sun protection. Which statement by the client indicates a need for further teaching? "I am better protected from the sun because I am dark skinned." "Sunscreen should be applied liberally." "I use a tanning bed to avoid the sun's harmful rays." "My sunglasses are UVA and UVB protected."
"I use a tanning bed to avoid the sun's harmful rays." Tanning beds are just as damaging to the skin as the sun's rays; the client stating that he or she uses a tanning bed indicates that the client needs further teaching. Dark-skinned people are better protected from the sun than light-skinned people. Regular use of sunscreen helps protect skin from the sun. Sunglasses with UVA- and UVB-protected lenses help shield the eyes from the sun's harmful rays.
When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider? A multicolored lesion is present on the client's thigh. Liver spots are present on both hands. Cherry hemangiomas are scattered on the client's back. The skin on the extremities is paper-thin.
A multicolored lesion is present on the client's thigh Color variation within a lesion is associated with skin cancer; the health care provider should be informed so that the lesion can be further assessed. Liver spots, cherry hemangiomas, and loss of skin elasticity are findings that are associated with aging and are normal for an older adult.
Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN? Develop a care plan for a client who has blisters caused by herpes zoster. Administer an antihistamine to a client who is describing pruritus. Teach a client how to self-assess for changes in skin lesions. Perform a baseline skin assessment for a newly admitted client.
Administer an antihistamine to a client who is describing pruritus. LPN/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects. Developing care plans and client assessment require more critical judgment and education and should be done by an RN. Providing client instruction is a more complex skill that is included in the RN scope of practice.
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road Adult client who needs to be admitted for a grafting of a second-degree burn on the right leg Middle-aged adult client who needs discharge teaching before going home after receiving steroids for Stevens-Johnson syndrome Older adult client with stage I pressure ulcers who needs to be turned every 2 hours
Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road An LPN/LVN would be familiar with wound monitoring for potentially contaminated wounds and would recognize the manifestations of infection. Conducting an admission assessment and discharge teaching are more complex nursing actions that require RN-level education and scope of practice. The older adult with stage I pressure ulcers who needs to be turned every 2 hours could be cared for by a nursing assistant.
Which statement made by a client with a furuncle in the groin indicates to the nurse that teaching about the care needed for this problem has been effective? A. "I will wear tight jeans to keep the infection from spreading to other areas." B. "I will shower with an antibacterial soap before applying the topical ointment." C. "I will squeeze the lesion until it opens so I can remove all the pus and other material." D. "I will shave the area around the lesion and apply cortisone cream to reduce the inflammation."
Answer: B Cortisone cream reduces the inflammatory response and increases the infectious process. Squeezing the lesion can lead to cellulitis as the material spreads through the tissue layers. Wearing tight jeans increases the moisture and promotes bacterial growth. Cleansing thoroughly and applying the antibiotic ointment can eliminate the infection.
The client who has stage III metastatic melanoma and whose tumor is negative for a BRAF mutation asks why the treatment plan does not include the new drug Zelboraf (vemurafenib) that she has read about. What is the nurse's best response? A. "Your immune system is too weak to tolerate Zelboraf." B. "This drug is experimental and too dangerous for you to take before trying other therapies." C. "Your melanoma does not have the gene mutation that responds to this drug, so you would not benefit from this therapy." D. "You are young and can better tolerate the standard therapies for melanoma that have been proven effective but have strong side effects."
Answer: C Rationale: Zelboraf is a targeted therapy that inhibits an enzyme made by the BRAF gene with a V600E mutation. The enzyme enhances the growth and metastasis of melanoma cell. If the melanoma does not have this specific mutation, Zelboraf has no effect on the cancer. About 50% of melanomas have the mutation that would make the cancer cells sensitive to the treatment. For melanomas without the mutation, Zelboraf would have no therapeutic effect.
Which precaution is most important for the nurse to teach the 32-year-old female client prescribed topical tazarotene (Tazorac) cream for psoriasis? A. Apply a dressing over the site with each application. B. Stop the drug use when psoriasis symptoms decrease. C. Report symptoms of infection to the prescriber immediately. D. Adhere to strict contraceptive measures while using the drug.
Answer: D Rationale: Tazarotene is highly teratogenic (can cause birth defects) even when used topically. Teach sexually active women of childbearing age using this drug to adhere to strict contraceptive measures. Lesions should not be dressed, and the drug should not be stopped without consulting the prescriber. Tazarotene does not alter the immune response and thus does not increase infection risk.
A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity does the nurse assign to an LPN/LVN working with this client? Teach the client about signs of incisional infection. Instruct the client about how to do dressing changes. Apply an antibiotic ointment and place a sterile dressing on the incision. Complete the written discharge instructions for the long-term-care facility.
Apply an antibiotic ointment and place a sterile dressing on the incision. Wound care is included in practical nursing education. Client teaching and instruction and completing discharge teaching are more complex skills that are included in the RN scope of practice.
Which method does the nurse use to assess skin lesions for cancer? American Cancer Society Skin Assessment Asymmetry, border, color, diameter, evolving Dermatologist skin review Size, location, and inflammation
Asymmetry, border, color, diameter, evolving The ABCDE (asymmetry, border, color, diameter, evolving) method is the accepted technique for assessing skin lesions. The American Cancer Society Skin Assessment, dermatologist skin review, and "size, location, and inflammation" are not methods for assessing skin lesions.
The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term-care client who has areas of skin breakdown in the skinfolds and the perineal area. Which intervention is best for the RN to delegate to the nursing assistant? Check the client's skin weekly for areas of redness or breakdown. Teach the client and family about the importance of good hygiene in skinfolds. Evaluate the client's ability to provide skin hygiene independently. Bathe the client, and apply a protective barrier to skinfolds and perineum.
Bathe the client, and apply a protective barrier to skinfolds and perineum. Assisting clients with personal hygiene is included in nursing assistant education. Assessment, teaching, and evaluation are more complex, higher-level skills that require the education and scope of practice of licensed nursing staff.
The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? Body image counseling Respiratory protection Self-suctioning Tobacco cessation education
Body image counseling The epidermis is the outer layer of the skin. Damage to the epidermis can cause body image disturbance for clients. Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.
The nurse notices yellowing at the corners of the sclera in an African-American client admitted for hepatitis. What does the nurse do next? Palpates the liver Checks the oral mucosa Examines the client's hair Monitors pulse oximetry
Checks the oral mucosa To assess dark-skinned clients for jaundice, check for a yellow tinge to the oral mucous membranes, especially the hard palate, and examine the sclera nearest to the iris rather than the corners of the eye. Although the liver is involved in hepatitis, palpating it is not the nurse's next action. Examining the hair and monitoring pulse oximetry are not indicated for this client.
Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? Clustered round lesions to the chest Five clustered circumscribed lesions on the chest Five diffuse circinate lesions on the chest Several lesions in one area that have well-defined borders
Five clustered circumscribed lesions on the chest "Five clustered circumscribed lesions on the chest" is specific, with correct terminology. "Clustered round lesions to the chest" and "five diffuse circinate lesions on the chest" use incorrect terminology. "Several lesions in one area that have well-defined borders" is too vague to describe the condition accurately.
An older immobile client has "sunk" to the bottom of the bed. What does the nurse do first? Gently pull the client up. Get help and lift the client. Look for broken skin areas. Pad the bony prominences.
Get help and lift the client. The client should be gently lifted with a sheet. Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority.
The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of the extremities is the nurse specifically concerned about? Slight tears on the forearms Fairly widespread dry flakiness Several smaller bruises on the extremities Marked dependent pitting edema
Marked dependent pitting edema Dependent pitting edema may indicate venous and cardiac insufficiency in clients with congestive heart failure. Skin tears may occur where adhesive tapes or dressings have been applied and removed, especially in older clients with fragile skin. Dry skin usually has scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.
Which skin condition will the emergency department nurse assess first? Localized redness of the surgical site Pitting edema Poor skin turgor Red bony prominences
Pitting edema Pitting edema indicates an electrolyte, cardiac, or renal insufficiency. Localized redness of the surgical site is the body's normal response to trauma. Poor skin turgor is not an urgent finding; it may be caused by age or dehydration. Bony prominences that are red are an important finding, but are not the first priority in this situation.
The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action does the nurse take first? Add potassium hydroxide to the specimen to check for a possible fungal infection and inspect it under the microscope. Soak the crust of a possible bacterial lesion with normal saline. Instruct the client who has had a punch biopsy about wound care. Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.
Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory. To obtain accurate results for clients who need viral cultures, the cultures should be immediately placed on ice and transported to the laboratory. Adding potassium hydroxide to the specimen to check for a possible fungal infection before inspecting it under the microscope, soaking the crust of a possible bacterial lesion with normal saline, and instructing the client about wound care do not require immediate action.
Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? 1-mm ecchymotic area on the upper extremity Presence of one of the "ABCDE" features Dark red color Round and raised appearance
Presence of one of the "ABCDE" features A lesion with one or more of the ABCDE features (asymmetry, border irregularity, color variation, diameter, evolving features) should be evaluated by a dermatologist or a surgeon. Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic.
The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? Cystic fibrosis Iron deficiency anemia Isolated periods of severe malnutrition Psoriasis
Psoriasis Pitting of the nails may be associated with plate thickening and onycholysis and most often involves several or all of the fingernails; it is seen in clients with psoriasis and alopecia areata. Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau's grooves are a sign of isolated periods of severe malnutrition.
During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? Clubbing of the nail beds Cool extremities Café au lait spots Reddish blue area on the calf
Reddish blue area on the calf A reddish blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention. Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Café au lait spots are not a postoperative concern.