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?

Accepted Answer

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

Question 2

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

Accepted Answer

Warts are benign skin lesions that are caused by a virus, specifically human papillomavirus (HPV). Pigmented nevi are moles and are not caused by a virus. Cysts are pockets of tissue filled with fluid or other material and are not caused by a virus. Keloids are raised scar tissue and are not caused by a virus.

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?

Accepted Answer

Impetigo contagiosa is a bacterial skin infection that can result in glomerulonephritis, a serious complication affecting the kidneys. Monitoring for signs and symptoms of kidney dysfunction should be included in the plan of care for this patient. Respiratory infection, basal cell carcinoma, and psoriasis are not typically associated with impetigo contagiosa.

Question 4

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

Accepted Answer

Pemphigus is a rare autoimmune disorder that causes blistering of the skin and mucous membranes. The blisters are usually large and filled with fluid, known as bullae. Wheals and vesicles are not typically seen in pemphigus. A rash is a non-specific term and could describe many different skin conditions.

Question 5

Which type of malignant skin lesion has the poorest prognosis?

Accepted Answer

Nodular melanoma is considered the most aggressive type of melanoma with the poorest prognosis, as it can grow quickly and metastasize early. Lentigo melanoma is the least aggressive type and usually progresses slowly. Squamous cell carcinoma and basal cell carcinoma, although considered malignant, usually have a better prognosis than melanoma.

Question 6

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

Accepted Answer

The development of a honey-colored crust over a thin-walled vesicle is a hallmark of impetigo contagiosa, a highly contagious bacterial skin infection. Carbuncles are deep skin infections that result in a painful, pus-filled lump, Scabies is a parasitic skin infestation, and Pediculosis is infestation with lice. None of these conditions typically present with honey-colored crusts over thin-walled vesicles.

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?

Accepted Answer

The answer of The nurse is caring for a patient...

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?

Accepted Answer

The first step in treating this pressure ulcer is to perform wound débridement to remove the necrotic or dead tissue, purulent discharge, and other debris in the wound. This will help promote healing and prevent infection. Antibiotic administration and wound cultures may be necessary after wound débridement. However, the focus initially is on cleaning the wound through débridement.

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?

Accepted Answer

A stage 3 pressure ulcer is characterized by full-thickness skin loss with damage to or necrosis of subcutaneous tissue. The wound bed should be visible, and granulation tissue, which has a grainy or spongy texture, should be present. This indicates that the body is actively working to heal the wound by forming new tissue. The presence of a hard crust or scab (B) may indicate that the wound is not healing properly and that the nurse may need to assess for infection. Serosanguinous drainage (C) is a normal sign of healing and indicates that there is some moisture in the wound, which is necessary to promote healing. Minimal pain (D) is a good sign, but it does not provide information on the state of the wound itself. Therefore, choice A is the best answer.

Question 10

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

Accepted Answer

The answer of A nurse is cleansing a patient's infected...

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?

Accepted Answer

Eschar is a black or brown necrotic tissue that forms due to the death of skin tissue. Therefore, the color to describe a pressure ulcer with eschar would be black.

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?

Accepted Answer

The patient's height and weight put them at a higher risk for pressure ulcers because there is less body surface area distributing their weight, making certain areas more prone to pressure and lack of circulation. Therefore, the best choice is D, High, indicating a higher risk for pressure ulcer development.

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?

Accepted Answer

The ulcer is 3 cm in diameter and 1 cm deep, indicating tissue destruction through the subcutaneous fat layer. The presence of tunneling on the left side also indicates deeper tissue damage. The ulcer also holds 17 mL of normal saline, indicating moderate drainage. The absence of visible fascia or bone means that the ulcer has not reached 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?

Accepted Answer

A yellow wound indicates infection as the wound has slough, which is yellow or green in color. A black wound indicates necrosis and a gray wound indicates older necrosis or eschar. A red wound indicates granulation tissue and healing.

Question 15

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

Accepted Answer

Patients with pemphigus are at high risk for infection due to the formation of blisters on the skin, which create a susceptible entry point for pathogens. Nurses should monitor for signs and symptoms of infection, provide proper wound care and infection control measures to prevent secondary infections, and educate patients on proper hygiene and infection prevention practices. The other options may not be as relevant to the care of a patient with pemphigus.

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?

Accepted Answer

Short, wavy, brownish black lines are the classic sign of scabies, which is a highly contagious skin infestation caused by the Sarcoptes scabiei mite. The mite burrows into the skin and lays eggs, causing intense itching and a rash with small, raised, red or flesh-colored bumps. Gray blue macules (A) are not typically associated with scabies. Reddish brown dots at the base of hairs (C) may indicate head lice, and large, fluid-filled blisters (D) may indicate a different skin condition, such as contact dermatitis or herpes.

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?

Accepted Answer

The hours between 10 a.m. and 4 p.m. are when the sun's rays are strongest, increasing the risk of skin damage and cancer. Avoiding sun exposure during these hours is a key preventive measure.

Question 18

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

Accepted Answer

The most important action for the nurse to prevent infectious skin disorders is to wash hands frequently. This is because many skin disorders are spread through contact with contaminated surfaces and objects, and frequent hand washing can help prevent the spread of germs. Isolation precautions and sterilizing contaminated objects are also important, but they are not as effective as hand hygiene in preventing the spread of skin infections. The use of antibacterial soap is not necessary for routine hand washing and may contribute to the development of antibiotic-resistant bacteria.

Question 19

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

Accepted Answer

Acute pain is a priority nursing diagnosis for a patient with herpes zoster as it is a common symptom associated with the condition. Pain management should be a primary focus to improve the patient's quality of life and prevent any further complications. While the other options may also be applicable, they are not the priority in this scenario.

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?

Accepted Answer

Varicella zoster is the virus responsible for shingles. Herpes simplex 1 and 2 are responsible for other types of herpes infections, and herpes zoster is simply another name for shingles.

Quiz 54: Nursing Care of Patients With Skin Disorders