Question 1

The nurse is providing care for a patient with an open pressure injury on the right hip. The bed of the wound is covered with thick, black eschar and the tissue around the wound is red and warm to the touch. Which action does the nurse take in anticipation of the type of debridement used for this pressure injury?

Accepted Answer

The presence of thick, black eschar on a pressure injury indicates that the wound is in a state that likely requires surgical debridement to remove the nonviable tissues. This is because eschar, a hard covering of dead tissue, can impede the healing process and might harbor infection. Surgical debridement is the fastest way to remove such tissue and is typically done in an operating room setting.

Question 2

The nurse at an HCP's office is interviewing a patient presenting with a skin infection. Which question by nurse will provide the least important information?

Accepted Answer

Asking the patient if they think they are contagious is the least important because it is subjective and based on the patient's non-professional opinion, rather than objective signs, symptoms, or history that can guide diagnosis and treatment.

Question 3

The community nurse is working with a family who has had multiple infestations of pediculosis capitis over a period of several months. Which comment by the parent indicates that nursing information is now likely to be effective?

Accepted Answer

Washing all hats and linens in hot soapy water is an effective measure to eliminate lice and prevent reinfestation, indicating that the parent is following appropriate advice.

Question 4

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

Accepted Answer

The grainy, spongy texture indicates granulation tissue formation, which is a sign of healing in a stage 3 pressure injury.

Question 5

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

Accepted Answer

The Braden Scale assesses risk factors for pressure ulcers, including nutrition (A), sensory perception (B), moisture (C), and mobility (D). Eating only half of the food, responding only to painful stimuli, needing frequent linen changes due to moisture, and requiring assistance for position changes all increase risk. Walking independently (E) does not increase risk.

Question 6

The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention does the nurse anticipate will be least effective?

Accepted Answer

Positioning patients at a 45-degree angle when on their side can increase the risk of pressure injuries by placing more pressure on the hip and shoulder areas, making it a less effective intervention compared to the others listed.

Question 7

A patient in the emergency department has bright red edematous plaques along an uneven line that runs from under the right arm toward the chest. The patient states that the breakout was sudden and is very painful. Which information does the nurse need to obtain first?

Accepted Answer

The description of bright red edematous plaques along an uneven line is indicative of shingles (herpes zoster), which is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. Therefore, verifying if the patient has ever had chickenpox is crucial because only individuals who have had chickenpox in the past can develop shingles.

Question 8

The nurse is providing care for a patient with limited mobility. The nurse notes that the head of the patient's bed is frequently at 45 degrees of elevation and the patient is slouched in the bed. Which area of the patient needs to be inspected carefully?

Accepted Answer

When a patient is slouched in bed at a 45-degree angle, there is increased pressure on the coccyx and buttocks, making them susceptible to pressure ulcers.

Question 9

The nurse is providing care for a patient who is immobile and being treated for diabetes mellitus and a urinary tract infection. Which intervention is included in a plan of care to prevent pressure injuries in this patient? (Select all that apply.)

Accepted Answer

Applying moisturizer after bathing helps maintain skin integrity. Repositioning the patient every 2 hours reduces pressure on any one area. Elevating the head of the bed no more than 30 degrees helps prevent shearing forces. Ensuring the skin is dried carefully after washing prevents moisture-related skin breakdown. Donut-shaped cushions are not recommended as they can actually increase pressure on surrounding tissue.

Question 10

The nurse works in a clinic that specializes in the care of patients diagnosed with psoriasis. Which patient does the nurse identify as being the greatest challenge for management of the disease?

Accepted Answer

Strep throat, a common trigger for psoriasis flare-ups, especially in children, can make management challenging due to the recurrent nature of strep infections. This can lead to frequent exacerbations of psoriasis, complicating treatment and management.

Question 11

A patient is diagnosed with dermatomycosis. Which statement by the patient gives the nurse an idea of where the infection was acquired?

Accepted Answer

Dermatomycosis is a fungal infection of the skin, often acquired in warm, moist environments where fungi thrive, such as showers at a gym or club. Regular hair washing, pet ownership, or buying organic foods are not directly associated with an increased risk of contracting dermatomycosis.

Question 12

The nurse is preparing to begin a position in an extended-care facility. The RN shares that the administration is interested in research that guides the skin care of the residents. Which information does the nurse discover about best practices?

Accepted Answer

Gentle synthetic soaps are recommended for cleaning moist areas to prevent skin irritation and maintain skin integrity in residents of extended-care facilities.

Question 13

The nurse is providing care for a patient with an open pressure injury, which exhibits the manifestations of an infection. The HCP prescribes wound cleansing with normal saline at a pressure of 4 to 15 pounds per square inch. Which method of cleansing does the nurse use?

Accepted Answer

The answer of The nurse is providing care for a...

Question 14

The nurse in a high school clinic is aware of an unusually high incidences of cold sores among the student population. Which information from the nurse will be the most helpful in controlling the spread of the causative virus, HSV-1?

Accepted Answer

HSV-1, the virus responsible for cold sores, is highly contagious and can be spread through direct contact with the virus. This includes sharing items that come into contact with the mouth, such as lip products, drinks, and foods. Educating all students to avoid sharing these items can help control the spread of the virus. There is no vaccine for HSV-1, making options A, B, and D less effective or not feasible for controlling its spread.

Question 15

A patient comes into the HCP's office and reports a rash. The nurse notices a red rash on the patient's chest, back, arms, and legs. The patient describes an intense itching. Which question does the nurse ask to determine the type of dermatitis displayed by the patient?

Accepted Answer

The nurse should ask about changes in laundry products to determine if the rash is contact dermatitis, which can be caused by allergens or irritants in such products.

Question 16

The nurse is assisting at a community health fair by performing skin checks. Which characteristic is unexpected by the nurse when screening participants who are dark skinned?

Accepted Answer

The answer of The nurse is assisting at a community...

Question 17

The nurse is assisting with preparation for cryosurgery for a patient diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the nurse provide regarding the events related to this surgery?

Accepted Answer

Cryosurgery involves freezing the affected tissue, which typically results in minimal pain, thus severe pain and the need for pain medication (A) is not expected. A hemorrhagic blister (B) is not a typical immediate outcome; instead, the area may swell or redden. After cryosurgery, the treated area requires proper cleaning and care, often including the application of a prescribed ointment (C) to aid in healing and prevent infection. While cryosurgery is effective, the assertion that the lesion is likely to reappear and require follow-up treatment (D) is not accurate for all cases, as the effectiveness can vary based on the lesion's characteristics and the procedure's success.

Question 18

The nurse is providing care for a patient who has a stage 4 pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding does the nurse communicate to the registered nurse (RN) immediately?

Accepted Answer

A reddened area adjacent to the injury may indicate infection or further tissue damage, which requires immediate attention and intervention by the RN.

Question 19

A patient is admitted with a recent surgical wound that is infected and exhibits an open suture line. The HCP prescribes negative pressure wound therapy (NPWT). Which step in setting up the treatment does the nurse anticipate?

Accepted Answer

Negative Pressure Wound Therapy (NPWT) involves packing the wound loosely with a sterile sponge, which is then covered with an occlusive dressing. A vacuum device is attached to draw out fluid and increase blood flow to the area, promoting healing.

Question 20

A patient with an infected skin lesion is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement indicates to the nurse additional teaching is necessary?

Accepted Answer

Antibiotics should be taken for the full prescribed duration, even if symptoms improve, to ensure the infection is fully treated and to prevent antibiotic resistance.

Quiz 54: Nursing Care of Patients With Skin Disorders