Deck 54: Nursing Care of Patients With Skin Disorders

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?

A)Obtain sterile forceps and scissors for the health care provider (HCP) to use for mechanical debridement.
B)Read the instructions about how to apply and manage the use of a proteolytic enzyme.
C)Expect that the patient will be taken to surgery to remove any nonviable tissues.
D)Bring gauze and normal saline to the bedside for application of wet-to-dry dressings.

Answer 1

Expect that the patient will be taken to surgery to remove any nonviable tissues.

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?

A)"How long have you had the infection?"
B)"Do you think you are contagious?"
C)"What aggravates or alleviates symptoms?"
D)"What do you think caused your infection?"

Answer 2

"Do you think you are contagious?"

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?

A)"I have washed all hats and linens in hot soapy water."
B)"We are all using a medicated bath soap to kill the lice."
C)"I frequently check the scalps of the children for reinfection."
D)"We are no longer attending school, I am home schooling now."

Answer 3

"I have washed all hats and linens in hot soapy water."

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?

A)There is a hard crust over the wound.
B)The patient states that pain is minimal.
C)The wound drainage is serosanguinous.
D)The wound has a grainy, spongy texture.

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.)

A)Patient eats half of offered foods.
B)Patient responds only to painful stimuli.
C)Linen must be changed at least once per shift.
D)Patient makes body position changes with assistance only.
E)Patient walks independently outside of the room twice a day.

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?

A)Thoroughly dry all skin-to-skin surfaces after bathing.
B)Position patients at a 45-degree angle when on their side.
C)Place a pillow lengthwise under the calves of the legs.
D)Ensure an adequate intake of protein, calories, and fluid.

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?

A)Ask if the patient was around anyone with the chickenpox.
B)Attempt to discover where the patient was during the last 3 weeks.
C)Inquire if the patient has ever received a vaccine for herpes zoster.
D)Verify if the patient is aware of ever having a case of chickenpox.

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?

A)The coccyx and buttocks
B)The buttocks and the hips
C)The shoulder blades and coccyx
D)The heels and the back of the head

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.)

A)Apply moisturizer to the skin after bathing.
B)Reposition the patient at least every 2 hours.
C)Elevate the head of the bed no more than 30 degrees.
D)Place the patient on a donut-shaped cushion when sitting.
E)Assure that skin is dried carefully and completely after washing.

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?

A)An adult male with a family history of the skin disease
B)An adult female who is postmenopausal and smokes
C)A school-age patient who frequently has strep throat
D)An adult patient who has a stressful occupation

Question 11

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

A)"I wash my hair every day."
B)"I work out and shower at a club."
C)"I have never owned any pet."
D)"I always buy the organic foods."

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?

A)The importance of assessing for risk factors monthly
B)The practice of bathing residents with dry skin weekly
C)The cleaning of moist areas with gentle synthetic soaps
D)The need to use moisture wicking adult diapers at night

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?

A)A 30-mL syringe with an 18-gauge needle attached
B)A whirlpool bath in warm water and antiseptic soap
C)A hand-held showerhead directed at the open area
D)A needleless 30- to 60-mL syringe and normal saline

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?

A)Infected students need to stay out of school until the lesion is crusted over.
B)Students with an active lesion need to eat at a specific isolation table.
C)All students need to sustain from sharing lip products, drinks, and foods.
D)Any student who has not been infected needs to get immunized immediately.

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?

A)"Have you changed any of your laundry products?"
B)"Did you have any swelling of your lips or mouth?"
C)"Are you still using your usual grooming products?"
D)"Does anyone in your family have the same rash?"

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?

A)Keloid formation
B)Multiple birthmarks
C)Mongolian spots
D)Nevi

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?

A)Explain that pain medication is given for expected severe pain.
B)A hemorrhagic blister will form immediately after the procedure.
C)The area will be cleaned as ordered and a prescribed ointment applied.
D)The lesion is likely to reappear and follow up treatment is expected.

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?

A)Patient report of pain
B)Yellow wound drainage
C)A reddened area adjacent to the injury
D)Pink grainy appearance at wound edges

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?

A)Moist gauze is placed into the open wound.
B)The wound is packed loosely with a sterile sponge.
C)Pressure is applied and increased until drainage appears.
D)The wound is covered completely with thick, absorbent pads.

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?

A)"Once the swelling and redness are gone, I can stop taking the antibiotics."
B)"I should wash the area gently with antibacterial soap before applying a new dressing."
C)"Covering my pillow with plastic and cleaning it every day will help prevent additional infection."
D)"I will need to increase my fluid and fiber intake to prevent constipation from the pain medication."