Deck 13: Skin Care

Question 1

A nurse is educating a group of nursing assistants in long-term care on the prevention of skin tears. Which of the following interventions should the nurse include in the education? (Select all that apply.)

A) Lubricate the resident's skin with moisturizers twice daily
B) Ensure that the resident has adequate nutrition and hydration
C) Bathe the resident in hot soapy water
D) Avoid the use of lifting shifts when transferring the resident
E) Dress the resident in long sleeves and long pants to protect the extremities

Answer 1

Lubricate the resident's skin with moisturizers twice daily
Ensure that the resident has adequate nutrition and hydration
Dress the resident in long sleeves and long pants to protect the extremities

Question 2

An older patient complains of pruritus. The nurse suggests which of the following interventions to alleviate the patient's complaint? (Select all that apply.)

A) Use only nonperfumed laundry detergent and fabric softeners
B) Avoid sudden temperature changes
C) Wear loose-fitting clothing
D) Apply heat to affected areas
E) Exercise vigorously for at least 30 minutes daily

Answer 2

Use only nonperfumed laundry detergent and fabric softeners
Avoid sudden temperature changes
Wear loose-fitting clothing

Question 3

A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine (Zostavax). Which of the following information should the nurse include in the education?

A) Zostavax should only be given to individuals who have never had an episode of herpes zoster (HZ)
B) Zostavax is recommended for all individuals over age 60 that have no contraindications to the vaccine
C) Zostavax should not be given to anyone with a chronic cardiac or respiratory condition
D) Zostavax will always prevent an individual from developing Herpes Zoster

Answer 3

Zostavax is recommended for all individuals over age 60 that have no contraindications to the vaccine

Question 4

A nurse is caring for an older adult with xerosis. Which of the following interventions should the nurse include in the patient's plan of care? (Select all that apply.)

A) Encourage adequate fluid intake
B) Encourage daily baths of at least 20 minutes
C) Maintain a humid environment
D) Apply water-laden emulsions to skin immediately after bathing
E) Use only deodorant soaps when bathing

Question 5

The nurse is most concerned by observing when assisting with an older client's bath:

A) A firm, irregularly-shaped, pink-colored nodule
B) A slightly raised multicolor lesion with an asymmetrical, irregular border
C) A pearly papule with prominent blood vessels
D) Rough, scaly, sandpaper-like patches that are slightly tender

Question 6

A nurse is assessing an older patient and notes a cluster of fluid-filled vesicles on the right thoracic area. The nurse suspects HZ. The patient asks the nurse, "I really don't understand how I got shingles. I don't even know anyone who has this infection." The nurse includes which of the following in formulating a response to the patient?

A) HZ is caused by a reactivation of dormant varicella zoster virus within the sensory neuron of the dorsal root ganglion
B) HZ is caused by the same virus as chickenpox and requires exposure to an individual with active chickenpox
C) HZ is caused by the same virus as chickenpox and requires direct contact with an individual with HZ
D) HZ is caused by the varicella zoster virus and occurs only in individuals who were never previously exposed to the virus

Question 7

An older patient tells a nurse. "The nurse practitioner told me that these ugly purple bruises on my arms are called purpura and are due to fragile blood vessels. I still don't understand why this happens to me." The nurse responds based on the knowledge that: (Select all that apply.)

A) purpura is due to normal age-related changes.
B) the incidence of purpura increases with age.
C) purpura is a precancerous skin condition.
D) individuals who take blood thinners are especially prone to purpura.
E) individuals prone to purpura should make sure that affected areas are open to the air.

Question 8

Which of the following are subscales on the Braden Scale for predicting pressure ulcers? (Select all that apply.)

A) Nutrition
B) Moisture
C) Mobility
D) Age
E) BMI

Question 9

A nurse assesses a nursing home resident's pressure ulcer to be a "healing stage III." The primary reason reverse staging is never used is because:

A) even though all tissue layers are replaced as a wound heals, the healed skin is not as strong as it originally was.
B) not all tissue layers are replaced as a wound heals, and the healed skin is not as strong as it originally was.
C) reimbursement in nursing homes does not allow for reverse staging to be utilized.
D) the collagen layer is not replaced during wound healing.

Question 10

An older person is admitted to the hospital with an exacerbation of congestive heart failure. The nurse notes that the patient complains of severe itching at night and has a red rash on her torso. The patient is diagnosed with scabies. The patient asks the nurse, "How did I get something like this?" The best response by the nurse is:

A) "Scabies is highly contagious and spreads easily through physical contact."
B) "Scabies is commonly seen in older adults due to normal age-related changes in the skin."
C) "Scabies is only seen in older adults who have multiple chronic illnesses."
D) "Certain medications can make you more susceptible to contracting scabies."