Deck 54: Nursing Care of Patients With Skin Disorders

Question 1

The nurse is caring for a patient who has a stage 4 pressure ulcer that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding should be communicated to the RN immediately?

A)Yellow wound drainage
B)A reddened area adjacent to the ulcer
C)Patient report of pain
D)Pink grainy appearance at wound edges

Answer 1

A reddened area adjacent to the ulcer

Question 2

Which type of benign skin lesion is caused by a virus?

A)Pigmented nevi
B)Cyst
C)Keloid
D)Wart

Answer 2

Wart

Question 3

The nurse is caring for a patient who has impetigo contagiosa. Monitoring for which of the following complications should be included in the plan of care?

A)Glomerulonephritis
B)Respiratory infection
C)Basal cell carcinoma
D)Psoriasis

Answer 3

Glomerulonephritis

Question 4

The nurse is assessing a patient with pemphigus. What skin manifestations would the nurse expect to observe?

A)Bullae
B)Wheals
C)Vesicles
D)Rash

Question 5

Which type of malignant skin lesion has the poorest prognosis?

A)Lentigo melanoma
B)Squamous cell carcinoma
C)Basal cell carcinoma
D)Nodular melanoma

Question 6

The development of a honey-colored crust over a thin-walled vesicle is characteristic of which infectious skin disorder?

A)Carbuncle
B)Scabies
C)Impetigo contagiosa
D)Pediculosis

Question 7

The nurse is caring for a patient admitted to the hospital from a nursing home. The patient has a stage 3 pressure ulcer. The nurse is asked to document the wound appearance. What is the best way to initially document the appearance of the wound?

A)Use a ruler to accurately measure wound size.
B)Use a clock analogy to describe wound location.
C)Use objective terminology.
D)Take a photograph of the wound.

Question 8

The nurse is caring for a patient who has a pressure ulcer on the hip. The ulcer is filled with purulent discharge and has black areas over part of it. It is painful and has a foul odor. What must be done first for healing to occur?

A)Intravenous antibiotic administration
B)Topical antibiotic administration
C)Wound débridement
D)Wound culture

Question 9

The nurse is monitoring a patient's stage 3 pressure ulcer for healing during treatment. Which finding indicates that the nursing interventions have been effective?

A)The wound has a grainy, spongy texture.
B)There is a hard crust over the wound.
C)The wound drainage is serosanguinous.
D)The patient states that pain is minimal.

Question 10

A nurse is cleansing a patient's infected pressure ulcer. What type of equipment would be appropriate to use?

A)A needleless 60-mL syringe
B)A needleless 30-mL syringe
C)A 10-mL syringe with a 24-gauge needle
D)A 30-mL syringe with an 18-gauge needle

Question 11

The home care nurse is teaching a family how to describe a pressure ulcer to health-care providers using colors. What color would describe a pressure ulcer with eschar?

A)Black
B)Gray
C)Yellow
D)Red

Question 12

The nurse is caring for an immobile patient who is 5 feet, 11 inches tall and weighs 140 pounds. In planning care for the patient, which of the following does the nurse understand is the patient's risk level for developing a pressure ulcer?

A)Minimal
B)Low
C)Moderate
D)High

Question 13

When assessing a patient's pressure ulcer, the nurse finds that it is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline. There is no visible fascia or bone in the ulcer. What pressure ulcer stage should the nurse document?

A)Stage 1
B)Stage 2
C)Stage 3
D)Stage 4

Question 14

A home care nurse is caring for a patient with a pressure ulcer. The nurse is teaching the family how to describe the wound to health-care providers using colors. What color would describe an infected wound?

A)Black
B)Gray
C)Yellow
D)Red

Question 15

What nursing diagnosis would be most appropriate for a patient with pemphigus?

A)Imbalanced Nutrition: Less Than Body Requirements
B)Risk for Infection
C)Fluid Volume Excess
D)Self-Care Deficit: Skin Care

Question 16

The nurse is caring for a patient with lesions on the skin. Which of the following assessment findings would cause the nurse to suspect scabies?

A)Gray blue macules on the thighs and axillae
B)Short, wavy, brownish black lines
C)Reddish brown dots at the base of hairs
D)Large, fluid-filled blisters

Question 17

The nurse is teaching a patient skin care to prevent cancer. Which of the following instructions would be appropriate regarding time of day to avoid the sun?

A)7 to 9 a.m.
B)9 to 10 a.m.
C)10 a.m. to 4 p.m.
D)2 to 4 p.m.

Question 18

What action is most important for the nurse to take to prevent infectious skin disorders?

A)Use isolation precautions.
B)Wash hands frequently.
C)Use antibacterial soap.
D)Sterilize all contaminated objects.

Question 19

The nurse is providing care for a patient who has herpes zoster. What nursing diagnosis is a priority for this patient?

A)Risk for Infection
B)Acute Pain
C)Imbalanced Nutrition: Less Than Body Requirements
D)Anxiety

Question 20

The nurse is providing care for a patient with shingles. Which of the following statements would the nurse include in the patient teaching?

A)"Shingles is caused by herpes simplex 1 virus."
B)"Herpes zoster is a virus that is common in the elderly."
C)"Herpes simplex 2 causes shingles."
D)"Varicella zoster is the virus responsible for shingles."

Question 21

The nurse is caring for an immobile patient being treated for diabetes mellitus and a urinary tract infection. What should be included in a plan of care to prevent pressure ulcers in this patient? (Select all that apply.?

A)Reposition the patient at least every 2 hours.
B)Place the patient on a donut-shaped cushion when sitting.
C)Elevate the head of the bed no more than 30 degrees.
D)Apply moisturizer to the skin after bathing.
E)Massage bony prominences including hips and elbows.
F)Assure that skin is dried carefully and completely after washing.

Question 22

The nurse is providing discharge teaching for a patient with a large carbuncle on the back of the neck. The physician performs surgical incision and drainage under a local anesthetic and prescribes oral antibiotics and daily dressing changes with topical antibiotic ointment. A prescription for acetaminophen with codeine is also provided. Which of the following statements indicates further teaching is necessary?

A)"I will need to increase my fluid and fiber intake to prevent constipation while I'm taking the pain medication."
B)"Once the swelling and redness are gone, I can stop taking the antibiotics."
C)"I should wash the area gently with antibacterial soap before applying a new dressing."
D)"Covering my pillow with plastic and cleaning it every day will help prevent additional infection."
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 23

The nurse is preparing a patient with a history of psoriasis for ultraviolet light therapy with psoralen (PUVA). What is important for the nurse to teach the patient prior to initiating therapy?

A)"It is expected that you will experience pain and burning at the treatment sites."
B)"You will need to take your psoralen tablets for 1 week following the treatment."
C)"Plan to wear dark glasses during the treatment, and for the whole day following treatment."
D)"You will need to return in 1 week for blood tests for liver function."

Question 24

What is the function of vitamin A acid (tretinoin [Retin-A]) in the treatment of acne vulgaris? (Select all that apply.?

A)It kills bacteria in follicles.
B)It loosens pore plugs.
C)It stabilizes hormone levels.
D)It decreases scarring.
E)It prevents occurrence of comedomes.
F)It stimulates the immune system.

Question 25

The nurse is assisting with a community education program on prevention of skin cancer. Which of the following factors should the nurse teach patients may contribute to the development of skin malignancies? (Select all that apply.?

A)Immunosuppressive therapy
B)Exposure to ultraviolet (UV) rays
C)High-fat diet
D)Fair skin
E)Use of sunscreen preparations