Question 1

A nurse evaluates the following data in a client's chart:

Based on this information,which action should the nurse take?

Accepted Answer

The white blood cell count is not directly related to nutritional status.Albumin,prealbumin,and lymphocyte counts all give information related to nutritional status.The prealbumin count is a more specific indicator of nutritional status than is the albumin count.The albumin and lymphocyte counts given are normal,but the prealbumin count is low.This puts the client at risk for inadequate wound healing,so the nurse should request a dietary consult.The other interventions do not address the information provided.

Question 2

A nurse cares for older adult clients in a long-term acute care facility.Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)

Accepted Answer

Using a lift sheet will prevent shearing forces from tearing skin.Tape should be avoided so that the skin won't tear.Using pressure-relieving devices for clients who are at risk for pressure ulcer formation,including older adults,is a proactive approach to prevent skin breakdown.No contraindication to using whirlpool therapy for the older client is known.Dressings should be applied as prescribed,not so loose that they do not provide required treatment,and not so tight that they decrease blood flow to tissues.

Question 3

A nurse manages wound care for clients on a medical-surgical unit.Which client wounds are paired with the appropriate treatments? (Select all that apply.)

Accepted Answer

Necrotic tissue should be removed so that healing can take place.Whirlpool treatment can gently remove the necrosis.A wound covered with eschar most likely needs surgical débridement.Warm water would not be recommended for a client with erythema.A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers,respectively.

Question 4

A nurse delegates care for a client who has open skin lesions.Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)

Accepted Answer

All health care providers should follow Standard Precautions when caring for clients who have any open skin areas.This includes hand hygiene and wearing gloves when in contact with the lesions.The UAP is not qualified to assess the client's skin.The other statements are not appropriate for the care of open skin lesions.

Question 5

A nurse prepares to admit a client who has herpes zoster.Which actions should the nurse take? (Select all that apply.)

Accepted Answer

Herpes zoster (shingles)is caused by reactivation of the same virus,varicella zoster,in clients who have previously had chickenpox.Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox.Herpes zoster is very painful and requires analgesia.Use of gloves and good handwashing are sufficient to prevent spread.It is best to put this client in a private room.Herpes zoster is a disease of immune suppression,so no one who is immune-suppressed should be in the same room.

Question 6

A nurse evaluates the following data in a client's chart:

Based on this information,which action should the nurse take first?

Accepted Answer

A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications.The health care provider needs this information quickly to plan other therapy for the client's wound.The nurse should contact the wound care nurse after alternative orders for wound care are prescribed.Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should be implemented as routine care for this client.A low-fat,high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care,vital signs,and telemetry monitoring.

Question 7

A nurse cares for a client who reports pain related to eczematous dermatitis.Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

Accepted Answer

For a client with eczematous dermatitis,the goal of comfort measures is to decrease inflammation and help débride crusts and scales.The nurse should implement cool,moist compresses and tepid baths with additives such as cornstarch.Topical corticosteroids are a pharmacologic intervention.A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

Question 8

A nurse plans care for a client who is immobile.Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Accepted Answer

A small pillow decreases the risk for pressure between bony prominences,a lift sheet decreases friction and shear,and heels have poor circulation and are at high risk for pressure sores,so they should be kept off hard surfaces.Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues.Fluids and proteins are important for maintaining tissue integrity.Clients should be repositioned every hour while sitting in a chair.A rubber ring impairs capillary blood flow,increasing the risk for a pressure sore.

Question 9

A nurse assesses a client who presents with an increase in psoriatic lesions.Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.)

Accepted Answer

Systemic factors,hormonal changes,psychological stress,medications,and general health factors can aggravate psoriasis.Psoriatic lesions are not triggered by chocolate,public showers,or international travel.

Question 10

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer,as shown below:

Which diagnostic test should the nurse anticipate being ordered for this client?

Accepted Answer

This lesion is suspicious for skin cancer and a biopsy is needed.A viral culture would not be appropriate.A Wood's lamp examination is used to determine if skin lesions have characteristic color changes.Diascopy eliminates erythema,making skin lesions easier to examine.

Quiz 25: Care of Patients with Skin Problems

A nurse evaluates the following data in a client's chart: Based on this information,which action should the nurse take?

A nurse cares for older adult clients in a long-term acute care facility.Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)

A nurse manages wound care for clients on a medical-surgical unit.Which client wounds are paired with the appropriate treatments? (Select all that apply.)

A nurse delegates care for a client who has open skin lesions.Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP) ? (Select all that apply.)

A nurse prepares to admit a client who has herpes zoster.Which actions should the nurse take? (Select all that apply.)

A nurse evaluates the following data in a client's chart: Based on this information,which action should the nurse take first?

A nurse cares for a client who reports pain related to eczematous dermatitis.Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

A nurse plans care for a client who is immobile.Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

A nurse assesses a client who presents with an increase in psoriatic lesions.Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.)

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer,as shown below: Which diagnostic test should the nurse anticipate being ordered for this client?