Deck 27: Care of Patients With Skin Problems

Question 1

The nurse determines that a client has a Braden Scale score of 9.Which is the nurse's best intervention related to this assessment?

A) Document the finding per protocol.
B) Reassess the client in 3 days.
C) Increase the client's fluid intake.
D) Consult with the health care provider.

Answer 1

Consult with the health care provider.

Question 2

When changing the dressing on a partial-thickness wound,a nurse observes small,pale pink bumps within the wound bed.Which action by the nurse is best?

A) Remove the bumps with a sterile scalpel.
B) Document and continue the current treatment.
C) Clean the wound vigorously to remove the bumps.
D) Culture the wound and place the client in isolation.

Answer 2

Document and continue the current treatment.

Question 3

Which dressing choice does the nurse make to protect a heavily draining deep pressure ulcer?

A) Wet-to-dry gauze
B) Dry cotton gauze
C) Alginate packing, dry gauze cover
D) Hydrocolloidal transparent film cover

Answer 3

Alginate packing, dry gauze cover

Question 4

A client has a chronic wound that is being treated with a vacuum-assisted wound closure (VAC)device.Which intervention by the nurse takes priority?

A) Provide pain medication as needed.
B) Assess the VAC every 2 hours for bleeding.
C) Check the integrity of the dressing seal every 4 hours.
D) Document the wound size with each dressing change.

Question 5

A client has urticaria and has been prescribed diphenhydramine (Benadryl).Which information is most important for the nurse to teach the client?

A) "Wear sunscreen when you are outside."
B) "Avoid drinking alcoholic beverages."
C) "Do not take aspirin-containing drugs."
D) "Take this medicine on a full stomach."

Question 6

The nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client.Which is the nurse's next best action?

A) Probe for a larger pocket of necrotic tissue.
B) Apply a transparent film dressing.
C) Measure the reddened area on the skin surface.
D) Apply alginate dressing daily.

Question 7

A client presents with a pressure ulcer on the ankle.Which is the first intervention that the nurse implements?

A) Draw blood for albumin, prealbumin, and total protein.
B) Prepare for and assist with obtaining a wound culture.
C) Place the client in bed and instruct him or her to elevate the foot.
D) Assess the affected leg for pulses, skin color, and temperature.

Question 8

When getting a client up in a chair,the nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks,heels,and scapulae.Which is the nurse's best action?

A) Turn the mattress overlay to the opposite side.
B) Do nothing because this is an expected occurrence.
C) Apply a different pressure-relieving device.
D) Reinforce the overlay with extra cushions.

Question 9

Which intervention best assists a client with pruritus?

A) "Keep your fingernails cut short and keep them clean."
B) "Drinking extra fluids decreases stimulation of itch receptors."
C) "Wear soft, breathable clothing made from material like cotton."
D) "Avoid immersing the areas in water and dry thoroughly after bathing."

Question 10

A client has a deep wound covered with a wet-to-damp dressing.Which intervention does the nurse include on this client's care plan?

A) Change the dressing every 6 hours around the clock.
B) Leave the dressing intact until next week.
C) Change the dressing when the current dressing is saturated.
D) Apply a new dressing when the seal breaks and the dressing leaks.

Question 11

Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound?

A) Ensure that the client is systemically oxygenated.
B) Restrict the client's movement with bedrest.
C) Cover the wound with an airtight dressing.
D) Apply hydrocortisone cream as ordered.

Question 12

A client is going home with a surgical wound on the coccyx that is to heal by second intention.Which priority problem must the nurse address in the teaching plan?

A) Pain
B) Infection
C) Poor body image
D) Dehydration

Question 13

Which nursing intervention best assists a bedridden client to keep skin intact?

A) Apply talcum powder to the perineal area.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Use a lift sheet to move the client in bed.

Question 14

Which client does the nurse assess to be at greatest risk for pressure ulcer development?

A) Client who has pneumonia
B) Client who requires assistance with ambulation
C) Client with hypertension on multiple medications
D) Incontinent client with limited mobility

Question 15

A client has a wound that is draining heavily.Which type of dressing does the nurse use on this wound?

A) Hydrophilic
B) Synthetic
C) Hydrophobic
D) Biologic

Question 16

Which finding puts a client at greatest risk for wound infection?

A) Immune compromised status
B) Presence of a deep wound
C) Severely reddened skin
D) Coexisting medical conditions

Question 17

Which client is receiving appropriate treatment?

A) Client with an ulcer and slight necrosis receiving whirlpool treatment
B) Client with an eschar-covered sacral ulcer receiving whirlpool therapy
C) Client with sunburn and erythema soaking in warm water for 20 minutes
D) Client with urticaria instructed to take warm showers twice a day

Question 18

A client has very dry skin.Which is the best intervention for the nurse to teach the client?

A) "Be sure to use lots of moisturizer several times a day."
B) "Avoid wearing stockings or other constricting clothing."
C) "Use antimicrobial soap so scratching won't cause infection."
D) "After you bathe, put lotion on before your skin is totally dry."

Question 19

Which statement made by the caregiver of a home care client indicates a need for clarification regarding pressure ulcer prevention and treatment?

A) "I help him shift his position every hour when he sits in the chair."
B) "I massage his tailbone every morning when he gets up because it is red."
C) "I apply lotion to his arms and legs every evening because they are so dry."
D) "He drinks a nutritional supplement between meals to maintain his weight."

Question 20

A client has a wound on his left trochanter that is 4 inches in diameter,with black tissue at the perimeter,and bone is exposed.Which is the nurse's best action?

A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage III pressure ulcer and start antibiotic therapy.
D) Document as a stage IV pressure ulcer and prepare the client for débridement.

Question 21

A client has been admitted for vacuum-assisted wound closure (VAC)treatment for a chronic leg wound.The client's past medical history includes atrial fibrillation and stroke,and medications include warfarin sodium (Coumadin)and sotolol (Betapace).Which action by the nurse is most appropriate?

A) Place the client on continuous telemetry monitoring.
B) Call the health care provider with this information.
C) Let the wound care nurse know that the client has arrived.
D) Order the VAC and gather other needed supplies.

Question 22

A home care client with a leg wound is unable to climb stairs to the second floor,where the bathtub is located.Which is the nurse's best intervention?

A) "I'll show you how to use a syringe to cleanse the wound."
B) "It is not necessary to clean this wound because it is not infected."
C) "You can use the kitchen sink and clean tap water for this purpose."
D) "You will have to come to the hospital each day for hydrotherapy."

Question 23

An African-American woman had a breast biopsy 1 year ago.The incision site is elevated,dark,and protruding.Which information does the nurse provide to the client?

A) A keloid has formed over the biopsy scar.
B) The benign tumor has undergone malignant changes.
C) A deep infection has probably become symptomatic.
D) Chronic inflammatory changes have occurred in the skin.

Question 24

The nurse assesses the client with which condition first?

A) Folliculitis
B) Furuncles
C) Cellulitis
D) Stage II ulcer

Question 25

The nurse is teaching a community group of older adults about skin problems.Which intervention by the nurse is most important?

A) Encourage them to get Zostavax.
B) Instruct them to monitor skin dryness.
C) Teach them how to moisturize skin.
D) Discuss how skin disorders are spread.

Question 26

A client had a skin graft with a pedicle flap.Which is the priority nursing intervention for this client in the early postoperative phase?

A) Monitor the donor site to detect hemorrhage.
B) Check the flap edges for adequate perfusion.
C) Turn the client often to prevent pressure ulcers.
D) Perform interventions to prevent contractures.

Question 27

Which question does the nurse ask to identify a possible trigger for worsening of a client's psoriatic lesions?

A) "Have you eaten a large amount of chocolate lately?"
B) "Have you been under a lot of stress lately?"
C) "Have you used a public shower recently?"
D) "Have you been out of the country recently?"

Question 28

The nurse notes that a client who has been using psoralens-ultraviolet A (PUVA)therapy for psoriasis for 1 month has darkening of the skin.Which is the nurse's best action?

A) Document this assessment finding.
B) Instruct the client to reduce the dose.
C) Instruct the client to drink more water.
D) Instruct the client to apply cortisone cream.

Question 29

The nurse sees a client with which condition first to evaluate for wound infection?

A) Pending blood cultures
B) Thin serous wound drainage
C) White blood cell count of 23,000/mm³
D) Decrease in wound size

Question 30

A client has been identified as being at risk for formation of pressure ulcers.Which dietary choices by the client indicate a good understanding of teaching related to this condition?

A) Low-fat diet with whole grains and cereals and vitamin supplements
B) High-protein diet with vitamins and mineral supplements
C) Vegetarian diet with nutritional supplements and fish oil capsules
D) Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

Question 31

The home health nurse is visiting a client who is treating a chronic wound.The nurse assesses that the client only performs daily wound care twice a week owing to cost.Which statement by the nurse best addresses this issue?

A) "You can use tap water instead of sterile saline to clean your wound."
B) "If you don't clean the wound properly, you could end up in the hospital."
C) "Sterile procedure is necessary to keep this wound from getting bigger."
D) "The only thing that really matters is good handwashing with wound care."

Question 32

A client has a group of vesicles on top of a red base on the trunk.The nurse prepares the client for which intervention?

A) Venipuncture for blood cultures
B) Tzanck smear and viral cultures
C) Cotton swab culture of the vesicles
D) Scraping of the lesions for examination

Question 33

Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus (MRSA)?

A) Client admitted from a nursing home with furuncles and folliculitis
B) Client with a leg cut and other trauma from a motorcycle crash
C) Client with a rash noticed after participating in sporting events
D) Client transferred from intensive care with an elevated white count

Question 34

The occupational health nurse is seeing several nurses with skin problems.The nurse with which condition was most likely infected by a client?

A) A herpes simplex virus 1 (HSV-1) oral lesion
B) Herpetic whitlow of the fingertip
C) Herpes zoster on one side of the body
D) Severe postherpetic neuralgia

Question 35

A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm³,prealbumin 15.2 mg/dL,albumin 4.2 mg/dL,and lymphocyte count 2000/mm³.Which action by the nurse is most appropriate?

A) Document the findings.
B) Request a dietary consult.
C) Place the client in isolation.
D) Assess the client's vital signs.

Question 36

The home care nurse is visiting an older adult client who has diabetes and "skinned his shin" yesterday.An intact scab is seen over the abrasion,and the skin around it is red,warm,and hard.Which is the nurse's best action?

A) Teaching the client how to apply cold compresses to the area
B) Lifting an area of scab to see whether any exudate can be expressed
C) Measuring the length and width of the red area
D) Calling the health care provider for a prescription to treat cellulitis

Question 37

A client at a community skin screening has numerous skin lesions.Which one does the nurse evaluate first?

A) Beige freckles on the backs of both hands
B) Irregular blue mole with white specks on the lower leg
C) Large cluster of pustules in the right axilla
D) Raised, tubular, white areas on the inner aspects of the wrists

Question 38

A client has a furuncle in the axilla.Which statement by the client indicates a good understanding of how to care for this condition?

A) "I'll apply cortisone cream to reduce the inflammation."
B) "I will squeeze the lesion until all pus is removed."
C) "I'll keep my arm down at my side to prevent spread."
D) "I will cleanse the area and apply warm compresses and antibiotic cream."

Question 39

An older client is observed scratching and rubbing white ridges on the skin between fingers,on the wrists,in the axillae,and around the waist.Which is the nurse's priority intervention?

A) Placing the client in a single room
B) Administering an antihistamine
C) Assessing for allergies
D) Applying cold compresses

Question 40

Which statement by a client with psoriasis indicates a need for further teaching?

A) "At the next family reunion, I'm going to ask my relatives if they have psoriasis."
B) "I have to make sure I keep my lesions covered, so I do not spread this to others."
C) "I expect that these patches will get smaller when I lay out in the sun."
D) "I should continue to use the cortisone ointment as the patches shrink and dry out."

Question 41

In assessing a client's wound,which finding assists the nurse in determining that the wound is infected?

A) It is open.
B) It has granulation tissue.
C) It is inflamed.
D) It has an odor.
E) It has heavy exudates.
F) It contains necrotic tissue.

Question 42

Which is the most important question for the nurse to ask a young adult woman about to begin taking isotretinoin (Accutane)?

A) "Do you spend a great deal of time in the sun?"
B) "Have you or any family members ever had skin cancer?"
C) "Which method of contraception are you using?"
D) "Do you drink alcoholic beverages?"

Question 43

In preparation for a client being admitted with herpes zoster,what does the nurse do?

A) Prepare a room for reverse isolation.
B) Assess staff for a history of or vaccination for chickenpox.
C) Check the admission orders for analgesia.
D) Choose a roommate who also is immune suppressed.
E) Ensure that gloves are available in the room.

Question 44

A client has a widespread fungal infection.For which drug does the nurse anticipate an order?

A) Clindamycin (Cleocin)
B) Acyclovir (Zovirax)
C) Linezolid (Zyvox)
D) Ketoconazole (Nizoral)

Question 45

Which preventive measures does the nurse use to prevent skin lesions in older adults?

A) Use a lift sheet when moving the client in bed.
B) Avoid tape when applying dressings.
C) Avoid any type of restraining device.
D) Avoid whirlpool therapy.
E) Use loose dressing on all wounds.
F) Apply dressings only when wounds are draining.

Question 46

The nurse assessing a client notices a lesion on the skin as shown in the photograph below.For which diagnostic test does the nurse prepare the client?

A) Punch skin biopsy
B) Viral cultures
C) Wood's lamp examination
D) Diascopy

Question 47

A client presents to the clinic with a swollen arm lesion that contains old blood and a sunken-in center.Which question by the nurse yields the most useful information?

A) "Have you traveled out of the country recently?"
B) "What do you do for a living or for hobbies?"
C) "Do you hike or engage in outdoor activities?"
D) "Are you exposed to places where spiders might be?"

Question 48

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized.Which interventions are appropriate?

A) Place a small pillow between bony surfaces.
B) Elevate the head of the bed to 45 degrees.
C) Limit fluids and proteins in the diet.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Keep the heels off the bed surfaces.
G) Use a rubber ring to decrease sacral pressure when up in the chair.

Question 49

A client who has had a rhinoplasty is swallowing frequently and belching.Which action does the nurse take?

A) Notify the surgeon.
B) Raise the head of the bed.
C) Assist the client with liquids.
D) Continue to assess.

Question 50

Which characteristic regarding leprosy is true?

A) A few cases have been found in underdeveloped countries.
B) Affected clients must be confined away from the general population.
C) Treatment with multiple antibiotic agents is necessary.
D) Treatment of leprosy involves immunosuppressive drugs.

Question 51

A client has methicillin-resistant Staphylococcus aureus (MRSA)and is receiving vancomycin (Vancocin)500 mg IV every 6 hours.What is an important nursing intervention related to this drug?

A) Administering it over 30 minutes using an IV pump
B) Giving the client diphenhydramine (Benadryl) before the drug
C) Assessing the IV site at least every 2 hours for thrombophlebitis
D) Ensuring that the client has increased oral intake during therapy

Question 52

The nurse inspects the site where a client's basal cell carcinoma has been treated with cryosurgery and finds that the area is red,with a blister in the center.Which action does the nurse take?

A) Culture the site.
B) Notify the surgeon.
C) Apply hydrocortisone cream.
D) Reassure the client.

Question 53

A client is at high risk for developing skin cancer but will not perform total skin self-examination (TSSE)consistently.Which nursing intervention is the most important?

A) Reinforce previous teaching on the TSSE technique.
B) Teach the client the dangers of skin cancer.
C) Determine whether the client has a partner to help.
D) Carefully document all existing skin lesions.