Tissue Integrity - Contact Dermatitis, Pressure Ulcers & Wound Healing
What are the goals of treatment for an alteration in skin integrity? (Select all that apply.) Improve perfusion Promote healing Prevent infection Control the severity Maximize mobility
promote healing prevent infection control the severity Rationale Goals of treatment for the client with an alteration in tissue integrity include promoting healing, preventing infection, and controlling the severity of the skin alteration. Goals of treatment for the client with an alteration in tissue integrity do not include maximizing mobility or improving perfusion.
Jackie Lamington, a 4-week old-infant, has been prescribed a topical medication to treat a skin rash over the abdomen and buttocks. What should the nurse teach Jackie's mother about applying this medication? "Use a large amount because the baby's outer skin layer is thick." "This medication won't absorb because of the greasy material on the baby's skin surface." "Apply the recommended amount as prescribed." "Apply the medication twice as often so that it absorbs through the thick subcutaneous tissue layer."
"Apply the recommended amount as prescribed" Rationale The skin of a newborn is thinner and has less subcutaneous fat than the skin of an adult. This permits faster absorption of topical medications. The nurse should instruct the mother to apply the recommended amount as prescribed. The baby's epidermis is not thick. At birth, the newborn's skin is covered with vernix caseosa; however, this baby is 4 weeks old. The baby's subcutaneous tissue layer is thin; therefore, applying the medication twice as often is not recommended as that may result in the baby receiving too much medication.
During a health history, the nurse observes a small area of skin excoriation around the rings that a client is wearing on the right hand. What question should the nurse ask the client at this time? "Are you experiencing any associated symptoms, such as itching" "How often is your skin exposed to direct sunlight?" "Did this problem start when you began wearing these rings?" "Have you made any changes to your diet recently?"
"Did this problem start when you began wearing these rings?" Rationale Because the client is experiencing excoriations of the skin on the fingers on which rings are being worn, the nurse needs to ask questions to determine if the problem is associated with the metal in the rings. Questions about diet, sunlight, or associated symptoms will not necessarily help the nurse determine the cause of the skin excoriation.
The nurse is performing a health history on a client who has been intermittently experiencing a red, itchy rash on the feet for the past 2 months. The client thinks it may be wool socks that are causing the rash. Which assessment question will allow the nurse to distinguish whether the client has allergic or irritant contact dermatitis? "How much does the rash itch?" "Do you have a fever when you have the rash?" "Does the rash look redder than when it first began?" "Does the rash go away quickly after you take the socks off?"
"Does the rash go away quickly after you take the socks off?" Rationale Asking about the course of the rash is the best way to distinguish between allergic and irritant contact dermatitis because irritant contact dermatitis resolves quickly after removal of the irritant. Allergic contact dermatitis may linger for up to 3 weeks following removal of the allergen. Asking about the severity of itching would not help distinguish between the two types of contact dermatitis. Asking if the rash looks redder or if fever accompanies the rash helps assess for the presence of infection but does not help distinguish between the two types of contact dermatitis.
The nurse is providing education to a client with allergic contact dermatitis caused by a new brand of sunscreen. Which statement made by the client indicates appropriate understanding of the teaching session? "My rash feels hot and painful, but it didn't when it first started." "I will only use this sunscreen once a week until my rash gets better." "I have been putting petroleum jelly on my rash with the corticosteroid cream." "I have been sleeping well since I started using the corticosteroid cream."
"I have been sleeping well since I started using the corticosteroid cream." Rationale If the client is sleeping well, then pruritus has been properly managed. The client should avoid the precipitating allergen, not use it less frequently. If the client's rash is newly hot and painful, this could be a sign of an infection that necessitates further treatment. Allergic contact dermatitis should be treated with drying lotions and treatments, not emollients that prevent water loss like petroleum jelly.
Mr. Brown is being treated for pressure ulcers. Mr. Brown has dementia and limited mobility, and he lives with his daughter, spending most of his day sitting in a chair. What should you suggest to Mr. Brown's daughter to help reduce his risk for pressure ulcers? "Place a memory foam pad on Mr. Brown's chair." "Have Mr. Brown stay in bed rather than sit in a chair." "Reposition Mr. Brown in the chair every 3 hours." "Have Mr. Brown sit in a more comfortable chair."
"Place a memory foam pad on Mr. Brown's chair." Rationale Mr. Brown's daughter can place a memory foam pad on the chair to reduce pressure on Mr. Brown's buttocks. Other devices to reduce pressure on body parts include gel flotation pads and pillows and wedges made of foam, gel, air, or fluid. Changing the chair Mr. Brown sits in or having him stay in bed will increase, not reduce, his risk of pressure ulcers. Repositioning should occur every 2 hours, not every 3 hours.
Mr. Flores has a chronic pressure ulcer, and test results show significant bacterial growth in the wound. The healthcare provider has prescribed larval therapy, and Mr. Flores asks you to explain how putting maggots on his pressure ulcer will help. Which is your best response? "The maggots are the fastest method for treating a pressure ulcer." "The maggots will eat the bacteria and reduce bacterial growth on your pressure ulcer." "The maggots will help your pressure ulcer to drain." "The maggots secrete an enzyme that will make your pressure ulcer less painful."
"The maggots will eat the bacteria and reduce bacterial growth on your pressure ulcer." Rationale Maggots eat bacteria, reduce bacterial growth on pressure ulcers, secrete enzymes that break down necrotic tissue, and keep healthy tissue intact. The maggots used in larval therapy do not help a pressure ulcer to drain and are not the fastest method of treating a pressure ulcer, and their enzymes do not necessarily make a pressure ulcer less painful.
Jackson Michaels, a 65-year-old male, is seen by a dermatologist for a suspicious skin esion on the right forearm. The healthcare provider believes that the lesion is cancerous. Mr. Jackson is upset and asks what the next step for him will be. Which response by the nurse is the most appropriate? "You will need to have a culture done on the lesion to determine if you have cancer." "The provider has ordered scratch tests for next week. We will know more after we do the procedure and get the results." "You will require months of chemotherapy to treat this cancer." "The provider has ordered a biopsy of the lesion. Prognosis and treatment will be determined once the results are back."
"The provider has ordered a biopsy of the lesion. Prognosis and treatment will be determined once the results are back." Rationale Skin lesions that are believed to be cancerous require a skin biopsy. Once the results of the biopsy confirm cancer, a treatment plan can be initiated. Telling the client he will require months of chemotherapy before a definitive diagnosis is made is not appropriate. Cultures are taken from skin wounds, not skin lesions believed to be cancerous. Scratch tests are used to diagnose allergies, not cancer.
The nurse is apply ointment to the affected skin area of a client with contact dermatitis. The client asks the nurse how this treatment is different from what was prescribed for the allergic dermatitis her husband had. Which response by the nurse is the most appropriate? "Treatment for irritant contact dermatitis focuses on promoting drying out the rash" "Treatment for ICD focuses on reducing water loss from the skin." "Topical antibiotics are always applied in conjunction with calcineurin inhibitors for irritant contact dermatitis." "Topical or oral corticosteriods rae the primary treatment for ICD."
"Treatment for ICD focuses on reducing water loss from the skin." Rationale Because ICD manifests with dry, scaling skin, treatment focuses on reducing water loss from the skin through the use of occlusive dressings and petroleum-based emollients. ACD is treated with corticosteroids and by drying out the rash. Topical antibiotics are only used if the client develops a secondary infection.
If a client's contact dermatitis develops a secondary infection, which medication will most likely be added to the treatment plan? An oral antiviral medication A topical corticosteroid A topical antibiotic An oral antihistamine
A topical antibiotic Rationale If a client develops a secondary bacterial infection with dermatitis, a topical antibiotic will be added to the treatment plan. A medication to reduce inflammation or itching, such as an antihistamine or corticosteroid, would not treat the infection. An antiviral medication is not used because the secondary infection is most likely a bacterial one.
How much fluid is recommended each day for a client recovering from an infected wound? At least 1,000 mL At least 2,000 mL At least 2,500 mL At least 1,500 mL
At least 2,500 ml Rationale The client who is recovering from a wound infection will require at least 2,500 mL of fluid each day unless this amount of fluid is contraindicated by another medical condition.
Which type of debridement causes the least damage to healthy and healing tissue surrounding a pressure ulcer? Mechanical Chemical Sharp Autolytic
Autolytic Rationale Autolytic debridement is the most selective type of debridement and causes the least damage to healthy and healing tissue surrounding a pressure ulcer. Sharp, mechanical, and chemical debridement take less time than autolytic debridement but cause more damage and are not as selective.
Timothy Hagen, a 16-year-old client, is prescribed an antibacterial medication to treat a skin infection on both arms. What should the nurse instruct Timothy about this medication? Cover the areas with an occlusive dressing Do not use with OTC agents containing peroxide Avoid exposure to sunlight Treatment may take several weeks
Avoid exposure to sunlight Rationale Advise the client to avoid exposure to sunlight and ultraviolet light when using an antibacterial agent. Anti-acne agents should not be used with OTC preparations containing salicylic acid, benzoyl peroxide, or sulfur.The full therapeutic effects of antivirals, not antibiotics, may take several weeks. An occlusive dressing is not required when taking an antibacterial as treatment for a skin infection.
When planning care for a client at risk for developing a pressure ulcer, the nurse addresses the potential problem of risk for impaired skin integrity. Which nursing intervention assists in meeting the goals of this diagnosis? (Select all that apply.) Keeping the head of the bed elevated more than thirty degrees Avoiding massaging bony prominence Using positioning devices Placing the client in the side-lying position only Inspecting the skin every day
Avoiding massaging bony prominence Using positioning devices Placing the client in the side-lying position only Inspecting the skin every day Rationale Using positioning devices such as pillows or foam wedges to protect bony prominences, not massaging bony prominences, and inspecting the skin daily help prevent skin breakdown and assist in meeting the goals of this diagnosis. Avoid placing the client in a side-lying position only or keeping the head of bed elevated more than thirty degrees because these positions can put pressure on specific body areas.
The nurse is caring for a client with a pressure ulcer who is at risk for impaired skin integrity. Which intervention should be included in the nursing plan of care? (Select all that apply.) Massaging bony prominences Increasing amount of time with the head of the bed elevated Avoiding the side-lying position Cleaning the skin at time of soiling and routinely Inspecting skin at least once a day
Avoiding the side-lying position cleaning the skin at time of soiling and routinely Inspecting skin at least once a day Rationale The plan of care should include inspecting the client's skin at least once a day, cleansing the skin routinely and when soiled with urine or feces. It is also appropriate to avoid the side-lying position. The plan of care should not include massaging the bony prominences or increasing the amount of time with the head of the bed elevated.
The nurse is caring for a client with a surgical wound. Which are the most appropriate goals for the client? (Select all that apply.) The client will maintain adequate hydration. The client will engage in activities that promote wound healing. The client will remain free of wound infection. The client will discontinue medications that may interfere with healing. The client will be comfortable, with pain at an acceptable level.
The client will maintain adequate hydration. The client will engage in activities that promote wound healing. The client will remain free of wound infection. The client will be comfortable, with pain at an acceptable level. Rationale Goals for clients with a healing wound center around adequate nutrition, hydration, infection prevention, and promotion of optimal wound healing. Pain control is also important for the client. The client should not stop taking prescribed medications without talking to the primary provider, even if the medications have the potential to delay wound healing or increase the risk of infection, such as corticosteroids.
While assessing the skin of a surgical client, the nurse observes erythema to the left scapulae. What is the best action for the nurse to take before reassessing the skin to determine if the erythema is a pressure ulcer? Massaging the scapulae with lotion Repositioning the client Applying a warm blanket Covering the area with a dressing
Repositioning the client Rationale The nurse needs to reposition the client to remove pressure from the scapulae and then reassess for redness in one-half or three-fourths the time it took to create the reddened area. If the reddened area does not clear, the client has a stage I pressure ulcer. Massaging the scapulae with lotion, applying a warm blanket, or covering the area with a dressing is not the best action before reassessing the client.
While receiving report, the nurse learns that a client being discharged from the operating room suite has a clean contaminated wound. For which body system should the nurse prepare to provide care to this patient? Musculoskeletal Endocrine Neurological Respiratory
Respiratory Rationale A clean contaminated surgical wound affects the respiratory, alimentary, genital or urinary tracts. A clean contaminated wound is not associated with surgery to the endocrine, neurological, or musculoskeletal systems.
What is the mechanism of action of an ointment? (Select all that apply.) Retards water loss Lubricates the skin Inhibits DNA replication Soothes irritation Decreases pain
Retards water loss Lubricates the skin Rationale Mechanisms of action for ointments include lubricating the skin and retarding water loss. Anesthetics decrease pain. Alternative therapy preparations soothe irritation. Antivirals inhibit DNA replication.
The nurse is discussing alternative therapies with the mother of a pediatric client with chronic contact dermatitis. Which therapies would the nurse suggest? (Select all that apply.) Peppermint Rice bran broth Vitamin C Aloe vera Probiotics
Rice bran broth Aloe vera Probiotics Rationale Aloe vera (applied topically), rice bran broth (used to bathe the skin), and probiotics (administered orally) are all common alternative therapies used to relieve symptoms of contact dermatitis in pediatric clients. Chamomile, not peppermint, and vitamin B12, not vitamin C, are other alternative therapies, although vitamin B12 may aggravate contact dermatitis in some cases.
A client with a wound infection has been receiving cephalexin 500 mg orally, 4 times a day. The lab report shows sensitivity to clindamycin. What action would the nurse expect from the health care provider? The provider will add clindamycin to the client's profile. The provider will change the antibiotic to clindamycin. The provider will not make any changes to the client's therapy. The provider will increase the dose of cephalexin.
The provider will change the antibiotic to clindamycin Rationale A culture and sensitivity test is performed when infection is suspected. A sensitivity report determines which medication is most effective in treating the infection. The nurse can expect the provider to change the client's therapy to the medication that is most appropriate to treat the infection.
During a physical examination, the nurse notes an area on a client's forearm that is a different color that the surrounding skin. The client reports the site was burned several years ago and, after healing, has not been able to tan. What does this finding suggest to the nurse? The stratum spinosum skin layer of the epidermis was damaged. The reticular layer of the dermis was damaged. The stratum basale skin layer of the epidermis was damaged. The papillary layer of the dermis was damaged.
The stratum basale skin layer of the epidermis was damaged. Rationale The stratum basale is the deepest skin layer of the epidermis and contains keratinocytes and melanocytes. These cells make melanin, which is a pigment that protects the keratinocytes and nerve endings from ultraviolet light damage. The different color appearance of the client's skin indicates damage in the stratum basale layer. The stratum spinosum layer contains cells that form the bone marrow and participates in mitosis. Keratin is not produced in either the papillary or reticular layers of the dermis.
A client is seen in the clinic after being discharged from the hospital for treatment of a pressure ulcer. Which client outcomes demonstrate to the nurse that the treatment goals are being met? (Select all that apply.) The wound has decreased in size. The client has enrolled in a smoking cessation program. The client's BMI is 16, and weight is down by 4 pounds. The client and family demonstrate an understanding of preventive care measures. There is greenish exudate on the dressing.
The wound has decreased in size The client has enrolled in a smoking cessation program The client and family demonstrate an understanding of preventative care measures Rationale There are several therapies that may be useful for wounds with impaired healing. Hyperbaric oxygen therapy improves oxygenation in nonhealing wounds. Skin grafts may be appropriate for some clients with nonhealing wounds. Biosurgery with sterile maggots may be used in wounds with necrotic tissue and slough to digest the unhealthy tissue. The size of the wound doesn't determine the treatment. An eviscerated wound requires surgery. Wounds in maturation are healed.
The nurse is preparing information on skin health for a community health fair. Why should the nurse include the importance of older individuals using sunscreen? The dermal-epidermal junction is flattened. There is less eccrine and apocrine activity. There are less active melanocytes. The subcutaneous tissue layer is thinner.
There are less active melanocytes Rationale As the skin ages, it loses a number of active melanocytes in the epidermis. This increases susceptibility to skin damage from sun exposure. A thinner subcutaneous tissue layer increases the risk of hypothermia and pressure ulcers. A flattened dermal-epidermal junction increases the risk for skin tears, purpura, and pressure ulcers. Less eccrine and apocrine activity can cause dry skin and reduce perspiration.
During the assessment of an adolescent client's skin, the nurse notes circular lesions on the upper back and shoulders. What health problems should the nurse consider as causing these lesions? (Select all that apply.) Tinea versicolor Ringworm Poison ivy Contact dermatitis Herpes zoster
Tinea versicolor Ringworm Rationale Circular lesions may indicate ringworm or tinea versicolor. Linear lesions may indicate poison ivy or herpes zoster. Grouped vesicles may be seen in contact dermatitis.
The nurse is completing discharge teaching for a client with a skin infection related to contact dermatitis. Which information should the nurse include to assist the client in managing this skin infection at home? (Select all that apply.) Seek medical attention if lesion becomes painful Avoid allergen that caused initial lesion Keep nails trimmed short Stop antibiotics when redness disappears Use mild soap to clean skin
Seek medical attention if lesion becomes painful Avoid allergen that caused initial lesion Keep nails trimmed short Use mild soap to clean skin Rationale The nurse needs to include client education on avoiding the precipitating allergen and using a mild soap to avoid further irritating the skin while at home. The nurse needs to include client education on seeking medical attention if lesion becomes painful, which will assist in wound healing. The nurse needs to include client education on the importance of practicing personal hand hygiene, which will assist in wound healing and avoid the spread of infection. The nurse needs to include client education on keeping the nails trimmed short, which will prevent additional skin damage if the lesion is accidentally scratched. Stopping antibiotics when redness disappears will not assist in wound healing. It is important that the nurse provides client education on completing the full course of antibiotics as prescribed.
Which conditions would require IgE antibody blood tests for allergen responses rather than skin testing? (Select all that apply.) Delayed allergen response Very large areas of contact dermatitis Medications that could trigger false positives Immediate allergen response Life-threatening allergic reaction
Very large areas of contact dermatitis Medications that could trigger false positives Life-threatening allergic reaction Rationale A client who experiences a life-threatening allergic reaction, is taking medication that could trigger false positive results, has very large areas of contact dermatitis, or has certain skin conditions will need to have blood tests for IgE antibodies rather than skin tests. Skin tests are commonly used to identify delayed and immediate allergen responses.
A client with type 1 diabetes mellitus has a blister on the left heel that resulted from improperly fitting shoes. The nurse should document this ulcer as being which stage? Stage II Stage IV Stage I Stage III
Stage II Rationale A stage II pressure ulcer is considered to be superficial and appears as a blister. Stage I ulcers have intact skin that doesn't blanch when pressed. Stage III pressure ulcers are deep open wounds with necrosis of subcutaneous tissue. Stage IV pressure ulcers have full-thickness skin loss with extensive tissue damage and necrosis.
A client is demonstrating signs of a skin infection. Which diagnostic test should the nurse expect to be prescribed for this client? Patch test Wood lamp Skin shaving Punch biopsy
Wood lamp Rationale Tests used to identify a skin infection include the Wood lamp. A patch test is used to identify an allergy. Punch biopsy and skin shaving are approaches to obtain a skin biopsy.
A client is being assessed by the health care provider for potential therapies for his sternal wound, which include hyperbaric oxygen therapy, skin grafting, and biosurgery. What would the nurse expect to observe when visualizing the client's wound? (Select all that apply.) Wound has necrotic tissue or slough Wound has eviscerated Wound has impaired healing Wound Is extremely large Wound is in the maturation phase
Wound has necrotic tissue or slough wound has impaired healing Rationale There are several therapies that may be useful for wounds with impaired healing. Hyperbaric oxygen therapy improves oxygenation in nonhealing wounds. Skin grafts may be appropriate for some clients with nonhealing wounds. Biosurgery with sterile maggots may be used in wounds with necrotic tissue and slough to digest the unhealthy tissue. The size of the wound doesn't determine the treatment. An eviscerated wound requires surgery. Wounds in maturation are healed.
The nurse is caring for a client with a pressure ulcer on the right elbow that is covered with eschar. The nurse should document this ulcer as being which stage? Stage I Stage IV Stage II Stage III
Stage IV Rationale A stage IV pressure ulcer may be covered with eschar. Eschar is not present with stage I, stage II, or stage III pressure ulcers.
Ms. Glenn presents to the emergency department with a pressure ulcer wound. Match the following examples and characteristics of the three different types of healing patterns. Instructions: Use the dropdown menus in the left column, to select the correct category for each statement in the right column. Category ▼ Primary intention healing (P) Tertiary intention healing (T) Secondary intention healing (S) Statement: Minimal scarring May have unresolved edema or infection Longest healing time Greatest scarring Minimal or no tissue loss Minimal granulation tissue Wound closed with sutures or staples Surgical wound left open to drain abscess Healing of pressure ulcer More susceptible to infection Wound closed with tissue adhesive Wound left open for 3-5 days Closed surgical wound Tissue surfaces approximated
P T S S P P T T S S P T P P Rationale •Primary intention healing occurs when the tissue surfaces have been approximated and there is minimal or no tissue loss. • Primary intention healing occurs when the tissue surfaces have been approximated with tissue adhesive, sutures, or staples. • Primary intention healing occurs when the tissue surfaces have been approximated and there is minimal or no tissue loss. • Primary intention healing is characterized by the formation of minimal granulation tissue and scarring. • Primary intention healing occurs when the tissue surfaces have been approximated with sutures, staples, or adhesive. • Primary intention healing occurs when the tissue surfaces have been approximated with sutures, staples, or tissue adhesive. • Secondary intention healing time is longer for a pressure ulcer, and scarring is greater. • Secondary intention healing usually leaves scarring because the pressure ulcer wound is not closed. • Secondary intention healing is prolonged due to the open wound and usual poor healing conditions of the client. • Secondary intention healing is more susceptible to infection because it is an open wound. • In tertiary intention healing the wound is left open for 3-5 days to allow edema or infection to resolve. • Tertiary intention healing is left open to allow edema or infection to resolve before closure. • In tertiary intention healing the wound is left open to allow for drainage from such wounds as a ruptured appendix or incised abscess. • Tertiary intention healing occurs from the inside out and is not closed until the infection is cleared to allow for proper healing.
The nurse carefully inspects a skin lesion that the nurse believes is due to contact dermatitis. Besides inspection, what other technique is important for the nurse to use during the nursing assessment of this client? Biopsy Auscultation Palpation Percussion
Palpation Rationale Besides observation, the nurse will palpate the lesion to determine its surface characteristics. The nurse will not use percussion or auscultation techniques. Nurses do not perform biopsies.
Maria Gonzalez, a 27-year-old dental hygienist, is experiencing problems with intermittent allergic skin reactions over small areas of her hands. She states that the problem developed over the last month. Her healthcare provider has suggested further evaluation of this condition. You anticipate an order for which diagnostic test? Complete blood count Urinalysis Patch testing IgE antibody testing
Patch testing Rationale The most common type of diagnostic study used to identify the source of delayed allergic alterations is the patch test. This involves placing an adhesive patch with common allergens on the back between the scapulae to determine whether or not there is an allergic reaction. IgE antibody testing is only used for life-threatening allergic reactions, for large areas of contact dermatitis, or if medications could trigger false positive results. Other tests such as a CBC and urinalysis are not diagnostic of allergic skin conditions.
Mrs. Como is bedridden and lives with her son and his family. You are helping to treat her for pressure ulcers that appear to be caused by frequent incontinence. While speaking with Mrs. Como, you learn that she feels ignored by her son and his family and is depressed about her situation. What should you include in the nursing care for Mrs. Como to address her situational low self-esteem? Encouraging Mrs. Como's family to bring her to the healthcare provider more often Teaching Mrs. Como's family how to conduct skin hygiene for her Encouraging Mrs. Como's family to speak to her more often Teaching Mrs. Como to rely on herself for her own skin hygiene A nurse is providing an older adult client who is bedridden with medication and water signifying culturally competent care across the life span.
Teaching Mrs. Como's family how to conduct skin hygiene for her Rationale Teach Mrs. Como's family how to conduct skin hygiene for her so that her human dignity is not compromised. Encouraging the family to speak to Mrs. Como more often or bring her to the healthcare provider more often will not improve her skin hygiene. Mrs. Como is bedridden and depends on her family to care for her, so teaching her to rely on herself for her own skin hygiene is not the most effective or a practical way to address the problem.
An 88-year-old client who has limited mobility is admitted to the hospital. Which action by the nurse prevents injury to the skin normally caused by friction? Avoiding use of a draw sheet when repositioning the client Elevating the head of the bed to a 60-degree angle Placing the client in the prone position Sprinkling baby powder on the sheets to keep the skin dry
Placing the client in the prone position Rationale To prevent injury to the skin caused by friction, the client should be turned every 2 hours using six different body positions, which include the prone position. Elevating the head of bed to a 60-degree angle, not using a draw sheet, and using baby powder cause injury to the skin as a result of friction.
During a home visit, the nurse determines that a client would benefit from teaching to promote tissue integrity. What did the nurse assess in order to come to this conclusion? (Select all that apply.) The client does not apply moisturizer after bathing. The client washes her hair every day. The client showers once a week. The client washes her hands with soap and running water before eating. The client does not wash her hands after using the commode.
The client does not apply moisturizer after bathing. The client showers once a week. The client does not wash her hands after using the commode. Rationale Independent nursing interventions to promote tissue integrity include teaching about skin hygiene to include daily bathing, explaining the use of liquid cleansers and the importance of thorough rinsing, and encouraging the use of skin moisturizers after bathing. Showering once a week, not washing the hands after using the commode, and not applying moisturizer after bathing indicate that teaching to promote tissue integrity is needed. Washing the hair daily and washing hands before eating are healthy habits to promote tissue integrity.
The nurse is assessing a client with a large abdominal surgical wound. Which assessment would concern the nurse that puts the client at risk of the complication of dehiscence? (Select all that apply.) The client shows signs of dehydration. The client has vomited 6 times in the last 4 hours. The client smokes a half pack of cigarettes per day. The client is 12 hours postop. The client is obese, with a BMI of 38.
The client shows signs of dehydration The client has vomited 6 times in the last 4 hours The client is obese, with a BMI of 38 Rationale Dehiscence usually involves an abdominal wound; the layers above and below the skin separate. The bowel may protrude into the opening. Risk factors for dehiscence include obesity, poor nutrition, multiple trauma, suture failure, excessive coughing, vomiting, or dehydration. It is most likely to occur 4dash-5 days postoperatively. Smoking is not an identified risk factor for dehiscence.
The charge nurse has just received the report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure ulcers? (Select all that apply.) The client who is on bed rest The client who has a history of anorexia nervosa The client who is 92 years old The client who is admitted to an acute care unit The client who has type 1 diabetes mellitus
The client who is on bed rest The client who has a history of anorexia nervosa The client who is 92 years old The client who has type 1 diabetes mellitus Rationale A client on bed rest is immobile, which creates a risk for developing pressure ulcers. An older client is at risk because of the loss of lean body mass, epidermal thinning, decreased skin elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissue. A client with a history of anorexia nervosa is at risk because of inadequate nutrition, which leads to weight loss, muscle atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure ulcer.
Which data should you record when assessing an existing pressure ulcer? (Select all that apply.) Color of the wound bed Location in relation to bony prominences Condition of the wound margins Odor of wound bed Signs of infection
Color of the wound bed Location in relation to bony prominence Condition of the wound margins Signs of infection Rationale When assessing an existing pressure ulcer, note the location in relation to bony prominence, color of the wound bed, signs of infection, and condition of the wound margins, among other factors. The odor of the wound bed is not a factor to note when assessing pressure ulcers.
Which treatments are appropriate for the wound complication of infection? (Select all that apply.) Manual pressure Emergency surgery Dressing changes Debridement Antibiotics
Dressing changes Debridement Antibiotics Rationale The client who experiences an infection in a wound would receive antibiotics, debridement, and dressing changes. Manual pressure is the treatment for the complication of hemorrhage. Emergency surgery is the treatment for hemorrhage and dehiscence.
Which factor contributes to the formation of pressure ulcers in a client and increases the cells' need for oxygen? Excessive body heat Immobility Diminished sensation Inadequate nutrition
Excessive body heat Rationale Excessive body heat increases the metabolic rate and the cells' need for oxygen. Immobility, diminished sensation, and inadequate nutrition contribute to the formation of pressure ulcers, but they do not increase the cells' need for oxygen.
The nurse is concerned that an older patient has an infected foot wound. What did the nurse assess to support this decision? (Select all that apply.) Increased heart rate Foul smelling wound bed Purulent drainage Sweating and chills Restlessness
Foul smelling wound bed Purulent drainage Sweating and chills Restlessness Rationale Manifestations of a skin infection include restlessness, purulent drainage, sweating and chills, and a foul smelling wound bed. Increased heart rate is a manifestation of pain.
The nurse is caring for a client with a stage I pressure ulcer to the sacrum. Which product should the nurse use to help increase blood supply to the skin of this pressure ulcer? Granulex Vacuum-assisted closure Transparent dressing Hydrogel dressing
Granulex Rational Granulex is a product that increases blood supply to the intact skin of a stage I pressure ulcer. A transparent or hydrogel dressing does not increase blood supply to intact skin of a stage I pressure ulcer. Vacuum-assisted closure increases the blood supply but should only be used on a stage IV pressure ulcer.e
While applying lotion to the skin of an older client, the client asks why it is more important to take better care of her skin now than when he was younger. Which dermatological features will the nurse describe to the client? (Select all that apply.) Greater sensitization to allergens over time Decreased turnover of the outer skin layer Increased efficiency of blood circulation to skin Faster wound healing Impaired skin barrier function
Greater sensitization to allergens over time Decreased turnover of the outer skin layer Impaired skin barrier function Rationale With age, the turnover of the outer skin layer of the skin (stratum corneum) decreases, which results in slower, not faster, wound healing. With age, greater exposure and sensitization to allergens occurs, causing older adults to be at greater risk for allergic contact dermatitis. Older adults also have impaired skin barrier function. However, older adults are less likely to develop irritant contact dermatitis due to the decreased, not increased, efficiency of blood circulation to the skin.
Mr. Ramirez asks the nurse about nonpharmacologic therapies to help heal his large surgical wound. Which therapies are appropriate for the client? (Select all that apply.) Hyperbaric oxygen therapy Specialty bandages Biosurgery NSAIDs
Hyperbaric oxygen therapy Specialty bandages Biosurgery Rationale Specialty bandages, hyperbaric oxygen therapy, and biosurgery are all examples of nonpharmacologic therapies. NSAIDs are anti-inflammatory medications used to treat pain and inflammation.
Which approaches can be used to obtain a skin biopsy? (Select all that apply.) Culture Incision Excision Punch Shaving
Incision Excision Punch Shaving Rationale Skin biopsies can be obtained through punch, incision, excision or shaving. Cultures are used to identify infections obtained from tissue samples, wounds, drainage, lesions, or serum.
What are the effects of aging on the subcutaneous skin layer? (Select all that apply.) Cellulite formation Wrinkle formation Increased abdominal fat Sagging breasts Double chin formation
Increased abdominal fat Cellulite formation sagging breasts double chin formation Rationale With aging, the subcutaneous tissue redistributes, causing sagging breasts, cellulite formation, double chin formation, and increased abdominal fat. Wrinkle formation is caused by elastic fiber degeneration in the dermis.
Ms. Greene is admitted to the hospital with a temperature of 102.5°F. She had abdominal surgery a week ago. The wound is draining a yellowish exudate and the surrounding skin is warm to the touch. The nurse receives an order for a culture and sensitivity of the drainage. What would the nurse include in the explanation of this lab test to the client? Indicates that a special dressing should be used Indicates how much pain to expect Indicates which antibiotic will be most effective for the infection Indicates whether another surgery is needed
Indicates which antibiotic will be most effective for the infection Rationale The culture identifies the organism responsible for the infection while the sensitivity determines which medication will be most effective in treating it. The lab test does not indicate the client's pain level; whether additional surgery is needed; or which type of dressing to use.
Mr. Frack is being discharged to home following vascular surgery with an incision to his right femoral area. He is a 72-year-old man who lives alone. He has neighbors who sometimes bring him meals and admits he doesn't cook much for himself. Which postoperative complication is this client most at risk of developing? Pain Hemorrhage Dehiscence Infection
Infection Rationale Poor nutrition and inability to keep an incision clean are both risk factors for infection for this client. Dehiscence is most likely to occur with an abdominal wound. Pain and hemorrhage are possible complications but not as likely for this client.
In which wound healing phase does hemostasis occur? Maturation phase Proliferative phase Granulation phase Inflammatory phase Approximation phase
Inflammatory phase Rationale Hemostasis occurs in the inflammatory phase and results from blood vessels vasoconstricting in response to the injury, fibrin deposits in the area, and blood clot formation. The proliferative phase is characterized by the addition of collagen and the formation of granulation tissue. The approximation phase is part of the proliferation phase as collagen forms and strengthens the edges of the wound. The maturation phase occurs when collagen formation becomes more organized and the scar becomes stronger, but may also lead to keloids, which are more prevalent in individuals with dark skin. The granulation phase occurs when capillaries grow on the wound to increase blood supply to the area. As they form a network, this tissue becomes translucent red and is called granulation tissue.
The results of a routine physical reveal that a 65-year-old client is 40 lbs. underweight. When planning care for this client, what should the nurse include to support body functioning? (Select all that apply.) Instruct client on the need to wear adequate clothing to prevent chilling Teach client to avoid the use of topical skin lotions Explain the need to receive adequate exposure to sunlight Recommend daily exercise followed by thorough bathing Review basic safety strategies to prevent injuries and falls
Instruct client on the need to wear adequate clothing to prevent chilling Review basic safety strategies to prevent injuries and falls Rationale The purpose of the subcutaneous tissue layer is to insulate and cushion the body. Because the client is 40 lbs. underweight, the client does not have much subcutaneous tissue. Interventions to support body functioning would include safety strategies because the client does not have much of a cushion. The nurse would also encourage the client to wear adequate clothing because the client does not have much insulation. There is no need to teach the client to avoid the use of topical skin lotions. Daily exercise and bathing would not necessarily support body functioning. Exposure to sunlight helps to synthesize vitamin D; however, there is no evidence to suggest that the client is experiencing a vitamin D deficiency. The issue is that the client has minimal subcutaneous tissue to protect and insulate the body.
The nurse identifies an alteration in tissue integrity in a client with a foot wound. Which independent interventions should the nurse include when caring for this client? (Select all that apply.) Encourage the use of moisturizers after bathing Instruct on cleaning and dressing the foot wound Teach the signs of wound infection Review the process to discard soiled dressings Instruct on skin hygiene to include daily bathing
Instruct on cleaning and dressing the foot wound Teach the signs of wound infection Review the process to discard soiled dressings Rationale Independent nursing interventions for the client with an alteration in skin integrity include teaching the signs of wound infection, reviewing the process to discard soiled dressings, and instructing on cleaning and dressing the foot wound. Instructions on skin hygiene and the use of moisturizers are independent nursing interventions to promote tissue integrity.
A client with allergic contact dermatitis is scheduled for a skin test in which small amounts of an allergen will be injected into the skin on the arm. Which test will the nurse educate this client about prior to performing? Scratch test Patch test IgE antibody test Intradermal test
Intradermal test Rationale An intradermal test involves the injection of small amounts of allergen into the skin on the arm. A patch test involves the application of an adhesive patch with common allergens on the back. A scratch test involves the application of small amounts of allergens to the skin. An IgE antibody test is a blood test for allergen antibodies.
During a home visit, the nurse suspects that a client with an alteration in skin integrity requires additional information about the disorder. Which behaviors did the nurse observe to come to this conclusion? (Select all that apply.) Kept wound on left forearm open to air Used daughter's brush to fix hair Washed hands 4 times in 1 hour Applied moisturizer after washing hands Applied a bandage over paper cut before preparing food
Kept wound on left forearm open to air Used daughter's brush to fix hair Washed hands 4 times in 1 hour Rationale Interventions to improve skin integrity include keeping the skin clean, dry, and moisturized and covering wounds. Additional teaching would be needed because washing the hands 4 times in 1 hour would be over-cleansing of the skin. Wounds should be covered; the wound on the left forearm needs a bandage. Personal items, such as brushes, should not be shared to reduce the risk of parasite transfer.
A client who is confined to bed is at risk for developing a pressure ulcer. What support surface should the nurse request for this client? Kinetic bed Alternating pressure mattress Memory foam mattress Gel flotation pads
Kinetic bed Rationale For clients who are confined to bed, the support surface needs to include a kinetic bed that provides oscillation therapy. Gel flotation pads, a memory foam mattress, and an alternating pressure mattress help to reduce pressure on specific body parts but are not the recommended support surface.
While conducting a routine physical examination, the nurse determines that a client is experiencing hyperplasia of melanocytes. What did the nurse assess to come to this conclusion? Double chin Cherry hemangioma Liver spots Purpura
Liver spots Rationale Hyperplasia of melanocytes can cause small areas of hyperpigmentation, or liver spots. Purpura is caused by the flattening of the dermal-epidermal junction. A double chin is caused by redistribution of adipose tissue. A cherry hemangioma is caused by proliferation of capillaries in the dermis.
Mr. Mathews is a 64-year-old African American man admitted to your unit with cellulitis. He reports that he has diabetes mellitus and shows you a scar from a previous surgery that has keloids. Which wound healing phase has the client achieved? Proliferative phase Inflammatory phase Maturation phase Hemostatic phase
Maturation phase Rationale Scars become stronger and more organized during the maturation phase. In some individuals, particularly those with dark skin, the scar becomes hypertrophic and is called a keloid. The inflammatory and proliferative phases are the first two phases of wound healing. There is no hemostatic phase.
A client is prescribed a medicated lotion to apply to a skin rash. What should the nurse teach the client about applying this medication? Place the lotion on the skin Cover the areas with an occlusive dressing Wrap the areas with a warm towel after applying Apply after bathing
apply after bathing Rationale When using a lotion, the client should be instructed to apply it after bathing while the skin is slightly damp. The lotion should be thoroughly rubbed into the skin and not just placed onto the skin. The area does not need to be covered with an occlusive dressing or wrapped with a warm towel after applying.
How does impaired mobility impact tissue integrity? (Select all that apply.) Promotes pressure ulcer formation Encourages skin breakdown Increases susceptibility to microorganisms Creates exudate Activates allergic response
encourages skin breakdown pressure ulcers Rationale Individuals with impaired mobility can experience skin breakdown and pressure ulcers. Exudate and increased susceptibility to microorganisms are infection responses to impaired mobility. Activation of an allergic response is an immune response.
You are completing a health history on 32-year-old Walter Powell, who is in the healthcare provider's office today with complaints of an intermittent skin rash over the last 2 weeks. Which statement would indicate that he may have an allergic condition? "I have lost 5 pounds since my last visit." "I have a sister who has eczema." "My blood pressure has been a little high since last week." "I occasionally have to get up at night to use the bathroom."
"I have a sister who has eczema." Rationale The nurse collects information during the assessment of the client that includes risk factors for allergic type skin alterations. Risk factors for allergic reactions include hereditary and genetic predisposition, repeated exposure to the same allergens over time, and individual sensitivity to specific allergens. The client statement of having a sibling with eczema means that he is at increased risk of having an inflammatory skin condition himself. Reports of elevated blood pressures, weight loss, and nocturia are unrelated to allergic skin conditions.
Which pathological finding characterizes irritant contact dermatitis but not allergic contact dermatitis? Rash confined to area of contact with allergen or irritant Pruritus Damage to the dermis and epidermis Not a hypersensitivity response
Not a hypersensitivity response Rationale Both types of contact dermatitis are characterized by pruritus (itching), damage to the dermis and epidermis, and a red rash confined to the area of contact with the allergen or irritant. Irritant contact dermatitis is not a hypersensitivity response, unlike allergic contact dermatitis.
A client is diagnosed with a severe case of allergic contact dermatitis, which covers 20% of the client's body. Which treatment can the nurse anticipate will be prescribed for this client that is specific to severe allergic contact dermatitis? Antipruritic medications Wet dressings Topical antibiotics Oral corticosteroids
Oral Corticosteroids Rationale The nurse can anticipate the healthcare provider ordering oral corticosteroids for a client with a severe case of dermatitis. Antipruritic medications will be ordered for a client with a minor case of dermatitis, not a severe case. Wet dressings will be ordered if the client has dermatitis with weeping lesions, regardless of whether or not the dermatitis is severe. Topical antibiotics will be ordered if the client has dermatitis that has lesions with secondary infections, regardless of whether or not the dermatitis is severe.
Which are nonmodifiable risk factors for the development of skin disorders? (Select all that apply.) Age Genetics Ethnicity Employment Diet
Age Genetics Ethnicity Rationale Nonmodifiable risk factors for skin disorders include age, genetics, and ethnicity. Diet and employment can be modified.
The nurse reviews a laboratory test prescribed for a client and considers that poor wound healing might be due to a nutritional imbalance. Which laboratory test did the healthcare provider prescribe for this client? Leukocytes Coagulation studies Hemoglobin Albumin
Albumin Rationale The albumin level determines nutritional status; a value below 3.5 g/dL indicates poor nutrition. The client could be at risk for poor healing and infection. Hemoglobin level is used to measure oxygen delivery to the skin. Leukocytes are used to determine if an infection is present. Coagulation studies are used to determine risk for bleeding or insufficient blood flow to a region.
When instructing a client about application of a topical corticosteroid cream medication, which instructions would be correct? Apply a thick layer of cream in a circular motion beginning at the center of the affected area. Cleanse the affected area with an exfoliating soap, dry the area, and apply the prescribed cream. Apply talcum powder to absorb moisture before applying the prescribed cream. Apply a thin layer of cream to slightly damp affected area.
Apply a thin layer of cream to slightly damp affected area. Rationale Corticosteroid creams should be applied in a thin layer. Leaving the affected area slightly moist will enhance their absorption. The skin should be clean and slightly damp but should not be washed with an exfoliating soap, which would be harsh and damage the skin. Talcum powder will reduce the absorption of the corticosteroid cream.
A client has multiple areas of bleeding underneath the epidermal layer of the skin caused by broken blood vessels. Which actions should the nurse prepare to provide to this client? (Select all that apply.) Apply soothing lotions to affected areas Apply ice to the areas Assist with debridement Cover areas with sterile, absorptive bandages Administer analgesics as prescribed
Apply ice to the areas Administer analgesics as prescribed Rationale The client has bruising. Interventions for bruises include applying ice to the areas and administering analgesics as prescribed. Debridement would be appropriate to remove eschar. Soothing lotions are used for pruritus. Covering the areas with sterile absorptive bandages would be used for wounds with exudate.
Latasha Montgomery, a 23-year-old college student, is scheduled for vaccinations before leaving on a trip to South America. What should the nurse instruct Latasha to do to prevent skin damage while vacationing? Apply sunscreen Bathe every other day Wear sleeveless shirts Increase hydration with water
Apply sunscreen Rationale Regardless of skin color, all types and tones of skin can be damaged by ultraviolet exposure. The nurse's role includes teaching all individuals to prevent sunburn and prevent the future development of skin cancer by using sunscreen. Bathing every other day and hydrating with water will not prevent skin damage. The nurse should instruct the client to wear protective clothing when outdoors. Sleeveless shirts may not be sufficient to prevent sun damage to the client's arms.
Ms. Small was admitted for an emergency appendectomy 2 days ago. Her dressing has been removed and the wound is exposed to air. Which will the nurse include in the wound assessment? (Select all that apply.) Assess for the presence of foul odor and pain. Appearance of the wound for healing, size, drainage, swelling, redness Check the dressing for drainage amount, color, odor, and use of drains Assess for fractures, internal bleeding, or abscess Inspect the wound edges for approximation
Assess for the presence of foul odor and pain Appearance of the wound size, healing, drainage, swelling, redness Inspect the wound edges for approximation Rationale The surgical wound should be assessed to determine whether the wound is healing without problems and the wound edges are well approximated, without any redness, drainage, or odors. She no longer has a dressing over her wound, so assessing the wound dressing does not apply here. However, the wound should be inspected for drainage, odor, appearance, size, swelling, and pain. There is no evidence of such other potential injuries as fractures, internal bleeding, or abscess.
Which action maintains skin hygiene for clients at risk for pressure ulcers? (Select all that apply.) Scrubbing the skin to clean it thoroughly when bathing Assessing the skin upon admission and then daily using the same screening tool Treating dry skin with moisturizing lotions directly applied to moist skin after bathing Cleaning the skin immediately if exposed to urine or feces Avoiding exposure to high humidity
Assessing the skin upon admission and then daily using the same screening tool Treating dry skin with moisturizing lotions directly applied to moist skin after bathing Cleaning the skin immediately if exposed to urine or feces Rationale To maintain skin hygiene for clients at risk for pressure ulcers, assess the skin upon admission and then daily, using the same screening tool, treat dry skin with moisturizing lotions directly applied to moist skin after bathing, and immediately clean the skin if exposed to urine or feces. Do not scrub the client's skin when bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity, not high humidity.
Which type of product or dressing for pressure ulcers forms a gel when it comes in contact with wound exudate? Hydrocolloid dressing Hydrofiber dressing Proteolytic enzymes Alginate dressing
Alginate dressing Rationale Alginate dressing forms a gel when it makes contact with wound exudate from pressure ulcers. Proteolytic enzymes, hydrocolloid dressings, and hydrofiber dressings do not.
The nurse identifies that a client admitted for decreased mental status is at risk for a pressure ulcer. Which action assists in maintaining skin hygiene to help prevent a pressure ulcer? Using hot water and mild soap during the bath Monitoring the skin once a week during the bath Applying lotion to moist skin after the bath Massaging bony prominences during the bath
Applying lotion to moist skin after the bath Rationale Moisturizing lotions applied directly to moist skin after bathing help maintain skin hygiene and prevent pressure ulcers. Massaging bony prominence can cause friction. Using hot water to bathe the client can dry the skin and cause injury, A skin assessment is done on admission and then daily.
Which is an age-related change in the skin that makes older clients more susceptible to contact dermatitis? Faster turnover of the stratum corneum Difficulty healing Improved skin barrier function Less exposure to allergens
Difficulty healing Rationale: With aging, the skin decreases in thickness, which leads to impaired skin barrier function and delayed wound healing. Older adults have slower turnover of the stratum corneum, not faster. Older adults also experience a greater exposure and sensitization to allergens over time, not less.
The nurse is teaching a young adult client about risk factors likely to cause allergic skin reactions. Of the possibilities, which ones would the nurse identify as possible risk factors? (Select all that apply.) Exposure to perfumes Exposure to soap Dry environment Infrequent hand washing Exposure to plants
Exposure to perfumes Exposure to soap Exposure to plants Rationale Soaps, perfumes, and other chemicals are possible triggers of allergic skin reactions. Plants like poison ivy are also triggers for allergic contact dermatitis. Moist environments and frequent hand washing, rather than dry environments and infrequent hand washing, are also risk factors for developing contact dermatitis.
The nurse is assessing a client with a red rash on the leg. Which assessment findings will differentiate the rash as allergic or irritant contact dermatitis? Erythema Vesicles Scaling Edema
Scaling Rationale Both allergic and irritant contact dermatitis cause erythema, edema, and vesicles. However, only irritant contact dermatitis causes scaling and skin dryness.
The nurse is educating a student about alginate dressings. On what type of pressure ulcer is this type of dressing used? (Select all that apply.) Stage II Stage III Stage I Stage IV without eschar Stage IV with eschar
Stage II, III and IV without eschar Rationale Alginate dressing should be used for pressure ulcers of stage II, III, and IV without eschar, but not for pressure ulcers of stage I or stage IV with eschar. An alginate dressing is not used for stage I, Alginate calcium Tegaderm can be used with stage I.
The nurse is caring for a client admitted with a pressure ulcer. Which data should the nurse document when assessing the pressure ulcer? (Select all that apply.) Home management of the pressure ulcer Stage of the ulcer Integrity of the surrounding tissue Color of the wound bed Signs of infection
Stage of the ulcer Integrity of the surrounding tissue color of the wound bed signs of infection Rationale Document the stage of the pressure ulcer, color of the wound bed, integrity of the surrounding tissue, and signs of infection. Assessment of home management does not need to be documented.
Julie Smith is a 44-year-old client who underwent a left mastectomy 2 days ago. Which factor will put Ms. Smith at the highest risk of a wound infection? Starting chemotherapy in 1 week Maintaining her BMI of 23 Continuing to walk every day Eating a protein bar every day
Starting chemotherapy in 1 week Rationale Eating a balanced diet high in protein, and exercising and maintaining an ideal body weight promote optimal wound healing. Such medications as anti-inflammatory drugs and antineoplastic agents may make a client more susceptible to infection due to suppression of the immune system. Taking pain medications does not increase risk of infection.
Which structures are found within the dermal skin layer? (Select all that apply.) Sweat glands Melanocytes Sebaceous glands Hair follicles Connective tissue
Sweat glands Sebaceous glands Hair follicles Rationale The dermis is the second layer of the skin and contains hair follicles and sweat and sebaceous glands. Melanocytes are found in the epidermis. Connective tissue is found in the hypodermis.
The nurse suggests to a mother that her child's rash should be examined instead of using an over-the-counter topical corticosteroid preparation on the skin area. Why did the nurse make this suggestion to the mother? The nurse does not believe the mother's description of the rash. The rash is located on the child's upper thighs. Topical over-the-counter preparations are not strong enough to treat the rash. The child is under one year of age.
The child is under one year of age Rationale Topical corticosteroids should not be used in infants under the age of one because of the risk of (rapid) systemic absorption. The location of the rash is not an issue. There is no reason for the nurse not to believe the mother's description of the rash. Topical over-the-counter preparations are sufficient to treat minor skin rashes and irritations.
What are the categories of skin disorders? (Select all that apply.) Excoriations Neoplastic Infectious Macules Inflammatory
Neoplastic Infectious Inflammatory Rationale The three groups of skin disorders are infectious, inflammatory, and neoplastic. Macules are a type of primary lesion. Excoriations are a type of secondary lesion.
To find possible precipitating causes for contact dermatitis, it is most important for the nurse to ask about what factor during the health history? Severity of symptoms Chief complaint Changes in detergents Changes in itching
Changes in detergents Rationale It is most important for the nurse to ask about any new detergents or other household chemicals (e.g., medications, soaps, skin care agents, or cosmetics) to find possible precipitating causes for contact dermatitis. Asking about changes in itching, severity of symptoms, and the client's chief complaint are important for assessing the nature of the dermatitis, but are not specific to finding the precipitating cause.
What is included in the assessment of the integument? (Select all that apply.) Nails Reflexes Texture Turgor Temperature
Nails Texture Turgor Temperature Rationale The assessment of the integument includes the nails, turgor, texture, and temperature. Reflexes are a part of the neurologic and musculoskeletal assessments.
A nurse identifies that a client has a pressure ulcer on the sacrum. Which assessment finding indicates that this is a stage III pressure ulcer? Skin loss to the dermis Damage identified to muscle and bone Non-blanchable erythema of intact skin Necrosis of subcutaneous tissue
Necrosis of subcutaneous tissue Rationale This client has a stage III pressure ulcer, which indicates that damage to the subcutaneous tissue has occurred. The necrosis extends down to but not through the underlying fascia. Exposed muscle and bone indicates a stage IV pressure ulcer. An area of nonblanchable erythema of intact skin indicates a stage I pressure ulcer, and skin loss to the dermis indicates a stage II pressure ulcer.
The nurse is performing a scratch test on a client with suspected allergic contact dermatitis. The client states, "I don't understand why I'm only getting this reaction now. This didn't happen to me the first time I used this detergent." Which response by the nurse is the most appropriate? "Your body is experiencing a delayed hypersensitivity reaction to the allergen and sending T cells to attack the allergen." "Once you stop using the detergent, your rash will disappear right away." "The first contact sensitized you to the allergen. You don't have an allergic reaction until the next exposure to the allergen." "Sometimes it takes time for your body to react. In some people it may be years until they react."
"The first contact sensitized you to the allergen. You don't have an allergic reaction until the next exposure to the allergen." Rationale With allergic contact dermatitis, the first exposure to the allergen sensitizes the client to the allergen, and manifestations of the allergy do not manifest until subsequent exposures. Stating that sometimes it takes time for the body to react does not explain the process to the client. With allergic contact dermatitis, removing the allergen does not guarantee rapid resolution of symptoms. In some cases, symptoms may remain for up to three weeks. Explaining the course of the condition also does not answer the client's question. The explanation of the pathology of allergic contact dermatitis may be too technical for the client and does not answer the client's specific question about the timing of symptoms.
You are providing home care teaching for 22-year-old Heidi Loeffler, who is diagnosed with a nickel allergy. She is prescribed a topical corticosteroid cream to apply to her contact dermatitis for 2 weeks. Which teaching point is most appropriate for you to provide to Ms. Loeffler? "You can stop using the cream before the 2 weeks are up if your rash gets better before that." "You should make sure any metal buttons or snaps on your clothes don't directly touch your skin." "You can wear jewelry with nickel in it if you only wear it for part of the day." "You can scratch the rash gently if the itching is too much to bear."
"You should make sure any metal buttons or snaps on your clothes don't directly touch your skin." Rationale Ms. Loeffler should place a barrier between the allergen and the skin, including any metal snaps on her clothing. She should avoid contact with the allergen altogether, not just reduce contact. She should use the corticosteroid cream for the entire prescribed time, not just until it gets better. Ms. Loeffler should avoid scratching since it increases the risk of infection.
