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 registered nurse (RN)immediately?

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

Answer 1

A reddened area adjacent to the ulcer

Question 2

The nurse is planning care for a patient with a malignant skin lesion.Which type of malignant skin lesion should the nurse realize has the poorest prognosis?

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

Answer 2

Nodular melanoma

Question 3

The nurse is providing care to a patient who has herpes zoster.What nursing diagnosis should the nurse identify as a priority for this patient?

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

Answer 3

Acute Pain

Question 4

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

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

Question 5

A patient has a pressure ulcer that has purulent drainage,areas if black material,foul smelling,and painful.What should the nurse do first for healing to occur?

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

Question 6

The nurse is caring for a patient with impetigo contagiosa.For which complication should the nurse monitor when caring for this patient?

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

Question 7

The nurse is caring for a patient with lesions on the skin.Which assessment finding should cause the nurse to suspect scabies?

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

Question 8

The nurse is teaching a patient skin care to prevent cancer.Which time of day should the patient instruct 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 9

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

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

Question 10

A patient's pressure ulcer is 3 cm in diameter and 1 cm deep and has tunneling on the left side.The ulcer holds 17 mL of normal saline and has 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 11

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,what should the nurse understand is the patient's risk level for developing a pressure ulcer?

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

Question 12

The nurse is participating in planning care for a patient with pemphigus.What nursing diagnosis should the nurse recommend be used to guide this patient's care?

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

Question 13

The nurse is care for a patient with shingles.Which statement should the nurse include in patient teaching?

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

Question 14

The nurse notes that a patient has a honey-colored crust over a thin-walled vesicle.For which infectious skin disorder should the nurse plan care?

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

Question 15

The nurse is cleansing a patient's infected pressure ulcer.What type of equipment should the nurse use?

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

Question 16

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

Question 17

The home care nurse is teaching a family how to describe a pressure ulcer to HCPs using colors.What color should the nurse use to describe a pressure ulcer with eschar?

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

Question 18

While caring for a patient with a pressure ulcer the home care nurse teaches the family how to describe the wound to health care providers (HCPs)using colors.What color should the nurse instruct that describes an infected wound?

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

Question 19

The nurses are reviewing actions to reduce the incidence of infectious skin disorders in patients admitted to the care area.What action should the nurses identify as being the most important to prevent infectious skin disorders?

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

Question 20

A patient is diagnosed with a benign skin lesion caused by a virus.For which skin condition should the nurse plan care for this patient?

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

Question 21

The nurse is planning care for an older patient to prevent skin breakdown.Which actions should be included in this patient's plan of care? (Select all that apply.)

A) Bathe daily with soap and water.
B) Examine skin for areas of breakdown or redness.
C) Remind to change positions on a regular schedule.
D) Apply alcohol-based solution to skin after bathing.
E) Ensure skin is cleansed after episodes of incontinence.

Question 22

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

Question 23

The nurse is completing the Braden scale to predict pressure ulcer development risk for a patient on bedrest.Which findings should the nurse score as increasing this patient's risk? (Select all that apply.)

A) Eats half of offered foods
B) Patient responds only to painful stimuli
C) Linen must be changed at least once per shift
D) Makes body position changes with assistance only
E) Walks independently outside of the room twice a day

Question 24

A patient with a carbuncle is prescribed oral antibiotics,daily dressing changes with topical antibiotic ointment,and acetaminophen with codeine for pain.Which patient statement indicates that further teaching about the care of this skin condition is necessary?

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

Question 25

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

Question 26

A patient is prescribed vitamin A acid (Retin-A)as treatment of acne vulgaris.What should the nurse instruct the patient about the purpose of this medication? (Select all that apply.)

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

Question 27

A patient with a wound is prescribed wet-to-dry dressings.What should the nurse do prior to performing a dressing change for this patient?

A) Assist the patient to void
B) Medicate the patient for pain
C) Wash hands and apply sterile gloves
D) Moisten the dressing before removing

Question 28

The nurse is planning care for a patient with dermatitis.What interventions should be included in this patient's plan of care? (Select all that apply.)

A) Pat the skin dry after bathing
B) Apply cool moist compresses
C) Encourage a high-protein diet
D) Provide skin care first thing in the morning
E) Keep fingernails short to prevent scratching

Question 29

The nurse is assisting a patient with psoriasis apply coal tar to the skin.What action should the nurse anticipate providing after the tar is applied to the patient?

A) Expose the patient UV light.
B) Application of occlusive dressings.
C) Have the patient sit in a warm environment.
D) Provide the patient with 16 ounces of warm fluids.

Question 30

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

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