chapter 54

  1. 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?

    a.

    Use a ruler to accurately measure wound size.

    b.

    Use a clock analogy to describe wound location.

    c.

    Use objective terminology.

    d.

    Take a photograph of the wound.
    ANS:    D

    A photograph is objective and easy to use as a baseline to monitor wound healing progress. Using a ruler, clock analogy, and objective terminology are all important but are not as clear a communication tool as a photograph for documenting appearance.
  2. 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?

    a.

    The wound has a grainy, spongy texture.

    b.

    There is a hard crust over the wound.

    c.

    The wound drainage is serosanguinous.

    d.

    The patient states that pain is minimal.
    ANS:    A

    Granulation tissue is a sign of healing and has a budding appearance, from the development of tiny new capillaries. If the granulations are healthy, they have a slightly spongy texture. A hard crust indicates eschar, which must be removed for healing to occur. Serosanguinous drainage indicates absence of infection, not healing. Minimal pain is a good outcome but is not a measure of healing.
  3. 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?

    a.

    Intravenous antibiotic administration

    b.

    Topical antibiotic administration

    c.

    Wound débridement

    d.

    Wound culture
    ANS:     C

    Débridement of nonviable tissue is necessary if there is an open wound. Débridement removes drainage and wound debris and permits granulation of tissue. After the wound is débrided, need for culture and additional treatment may be determined.
  4. 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?

    a.

    Stage 1

    b.

    Stage 2

    c.

    Stage 3

    d.

    Stage 4
    ANS:     C

    A stage 3 ulcer has full-thickness skin loss, which extends to the subcutaneous tissue but not fascia. The ulcer looks like a deep crater and may have undermining of adjacent tissue. Skin is still intact in stage 1; stage 2 is shallow; and stage 4 has damage to muscle and bone.
  5. 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?

    a.

    Yellow wound drainage

    b.

    A reddened area adjacent to the ulcer

    c.

    Patient report of pain

    d.

    Pink grainy appearance at wound edges
    ANS:     B

    A reddened area adjacent to the ulcer can indicate extension of the ulcer or infection and should be reported. Yellow drainage may indicate colonization and not true wound infection. Pain is not unexpected and can be treated by the LPN. Pink grainy appearance is a sign of healing.
  6. 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?

    a.

    Black

    b.

    Gray

    c.

    Yellow

    d.

    Red
    ANS:     C

    Pressure ulcers may be described according to a three-color system. Black wounds indicate necrosis. Yellow wounds have exudate and are infected. Red wounds are pink or red and are in the healing stage.
  7. 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?

    a.

    Black

    b.

    Gray

    c.

    Yellow

    d.

    Red
    ANS:    A

    Pressure ulcers may be described according to a three-color system. Black wounds indicate necrosis. Yellow wounds have exudate and are infected. Red wounds are pink or red and are in the healing stage. Eschar is a black or brown hard scab or dry crust that forms from necrotic tissue.
  8. 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?

    a.

    Minimal

    b.

    Low

    c.

    Moderate

    d.

    High
    ANS:    D

    The patient is very thin and is immobile, which makes the patient high risk for developing a pressure ulcer.
  9. A nurse is cleansing a patient’s infected pressure ulcer. What type of equipment would be appropriate to use?

    a.

    A needleless 60-mL syringe

    b.

    A needleless 30-mL syringe

    c.

    A 10-mL syringe with a 24-gauge needle

    d.

    A 30-mL syringe with an 18-gauge needle
    ANS:    D

    The ulcer should be thoroughly cleansed via whirlpool, handheld shower head, or irrigating system with a pressure between 4 and 15 pounds per square inch (psi), such as a 30-mL syringe with an 18-gauge needle. A smaller needle can generate too much pressure and damage new tissue. A needleless syringe may not generate enough pressure.
  10. 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?

    a.

    7 to 9 a.m.

    b.

    9 to 10 a.m.

    c.

    10 a.m. to 4 p.m.

    d.

    2 to 4 p.m.
    ANS:     C

    If exposure to the sun is necessary, exposure should be avoided during its highest intensity (10 a.m. to 4 p.m.).
  11. The nurse is assessing a patient with pemphigus. What skin manifestations would the nurse expect to observe?

    a.

    Bullae

    b.

    Wheals

    c.

    Vesicles

    d.

    Rash
    ANS:    A

    Pemphigus is an acute or chronic serious skin disease characterized by the appearance of bullae (large fluid-filled blisters) of various sizes on otherwise normal skin and mucous membranes. Wheals are usually allergic in origin. Vesicles are smaller fluid-filled lesions. Rash is a more general term.
  12. What nursing diagnosis would be most appropriate for a patient with pemphigus?

    a.

    Imbalanced Nutrition: Less Than Body Requirements

    b.

    Risk for Infection

    c.

    Fluid Volume Excess

    d.

    Self-Care Deficit: Skin Care
    ANS:     B

    The major complication of pemphigus is a secondary bacterial infection. Nutrition and self-care deficit would be determined based on assessment findings. Fluid volume deficit would be more likely than excess because of the oozing blisters.
  13. The nurse is providing care for a patient who has herpes zoster. What nursing diagnosis is a priority for this patient?

    a.

    Risk for Infection

    b.

    Acute Pain

    c.

    Imbalanced Nutrition: Less Than Body Requirements

    d.

    Anxiety
    ANS:     B

    The patient with herpes zoster experiences vesicles and plaques, irritation, itching, fever, malaise, and, depending on the location of lesions, visceral involvement. Lesions may be very painful; the likelihood of pain increases with age. The patient already has an infection. Anxiety and nutrition diagnoses would be based on assessment.
  14. What action is most important for the nurse to take to prevent infectious skin disorders?

    a.

    Use isolation precautions.

    b.

    Wash hands frequently.

    c.

    Use antibacterial soap.

    d.

    Sterilize all contaminated objects.
    ANS:     B

    Standard precautions should be used, including careful hand washing, when providing care for patients with infectious skin disorders to prevent transmission to self or to others.
  15. The nurse is providing care for a patient with shingles. Which of the following statements would the nurse include in the patient teaching?

    a.

    “Shingles is caused by herpes simplex 1 virus.”

    b.

    “Herpes zoster is a virus that is common in the elderly.”

    c.

    “Herpes simplex 2 causes shingles.”

    d.

    “Varicella zoster is the virus responsible for shingles.”
    ANS:    D

    Herpes zoster, or shingles, is caused by the varicella zoster virus. Herpes simplex 1 causes cold sores, and herpes simplex 2 causes genital herpes.
  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?

    a.

    Gray blue macules on the thighs and axillae

    b.

    Short, wavy, brownish black lines

    c.

    Reddish brown dots at the base of hairs

    d.

    Large, fluid-filled blisters
    ANS:     B

    The scabies parasite burrows into the superficial layer of the skin. These burrows appear as short, wavy, brownish black lines. Pediculosis pubis causes black or reddish brown dots (lice excreta) at the base of hairs or in underclothing. Gray blue macules may also be noted on the trunk, thighs, and axillae; this is the result of the insects’ saliva mixing with bilirubin. Large, fluid-filled blisters occur in pemphigus.
  17. The development of a honey-colored crust over a thin-walled vesicle is characteristic of which infectious skin disorder?

    a.

    Carbuncle

    b.

    Scabies

    c.

    Impetigo contagiosa

    d.

    Pediculosis
    ANS:     C

    An impetigo rash appears as an oozing, thin-roofed vesicle that rapidly grows and develops a honey-colored crust; crusts are easily removed, and new crusts appear; lesions heal in 1 to 2 weeks if allowed to dry. A carbuncle is a boil; a scabies rash may appear as small, scattered erythematous papules, concentrated in finger webs, axillae, wrist folds, umbilicus, groin, and genitals. Pediculosis causes a popular rash, minute hemorrhagic points, or black or reddish brown dots at the bases of hairs, depending on the type.
  18. Which type of benign skin lesion is caused by a virus?

    a.

    Pigmented nevi

    b.

    Cyst

    c.

    Keloid

    d.

    Wart
    ANS:    D

    Warts are caused by a virus. Pigmented nevi are often inherited. Keloids are caused by trauma and scarring. A cyst is caused by follicle blockage.
  19. Which type of malignant skin lesion has the poorest prognosis?

    a.

    Lentigo melanoma

    b.

    Squamous cell carcinoma

    c.

    Basal cell carcinoma

    d.

    Nodular melanoma
    ANS:    D

    Malignant melanoma is highly metastatic, with a higher mortality rate than basal or squamous cell carcinoma. There are three general types: lentigo maligna, superficial spreading, and nodular. Lentigo maligna melanoma appears as a slow-growing dark macule on exposed skin surfaces (especially the face) of elderly patients. The lesion has irregular borders and brown, tan, and black coloring. Prognosis is good if treated in the early stage. Nodular melanoma has the least favorable prognosis.
  20. 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?

    a.

    Glomerulonephritis

    b.

    Respiratory infection

    c.

    Basal cell carcinoma

    d.

    Psoriasis
    ANS:    A

    Glomerulonephritis can result from a particular strain of streptococcus infection that causes impetigo. B, C, and D are not complications of impetigo.
  21. The nurse is preparing a patient with a history of psoriasis for ultraviolet light therapy with psoralen (PUVA). What is important for the nurse to teach the patient prior to initiating therapy?

    a.

    “It is expected that you will experience pain and burning at the treatment sites.”

    b.

    “You will need to take your psoralen tablets for 1 week following the treatment.”

    c.

    “Plan to wear dark glasses during the treatment, and for the whole day following treatment.”

    d.

    “You will need to return in 1 week for blood tests for liver function.”
    ANS:     C

    Oral psoralen tablets (a photosensitizing agent) followed by exposure to UVA is called PUVA therapy. PUVA therapy temporarily inhibits DNA synthesis, which is antimitotic. Because psoralen is a photosensitizing agent, the patient must not only wear dark glasses during the treatment period, but also for the entire day after a treatment. The patient should be observed closely for redness, tenderness, edema, and eye changes, but these side effects are not expected.
  22. The nurse is providing discharge teaching for a patient with a large carbuncle on the back of the neck. The physician performs surgical incision and drainage under a local anesthetic and prescribes oral antibiotics and daily dressing changes with topical antibiotic ointment. A prescription for acetaminophen with codeine is also provided. Which of the following statements indicates further teaching is necessary?

    a.

    “I will need to increase my fluid and fiber intake to prevent constipation while I’m taking the pain medication.”

    b.

    “Once the swelling and redness are gone, I can stop taking the antibiotics.”

    c.

    “I should wash the area gently with antibacterial soap before applying a new dressing.”

    d.

    “Covering my pillow with plastic and cleaning it every day will help prevent additional infection.”
    ANS:     B

    Constipation is a potential complication of the prescribed pain medication and preventive measures such as increased fluid and fiber intake are important. Antibiotics should be taken for the complete course as ordered. It is important to cleanse surrounding skin with antibacterial soap, followed by application of antibacterial ointment. Cover mattress and pillows with plastic and wipe daily with a disinfectant to prevent spread of infection.
  23. What is the function of vitamin A acid (tretinoin [Retin-A]) in the treatment of acne vulgaris? (Select all that apply.)

    a.

    It kills bacteria in follicles.

    b.

    It loosens pore plugs.

    c.

    It stabilizes hormone levels.

    d.

    It decreases scarring.

    e.

    It prevents occurrence of comedomes.

    f.

    It stimulates the immune system.
    ANS: B, E

    Vitamin A acid (Retin-A, tretinoin) loosens pore plugs and prevents occurrence of new comedones. Antibiotics kill bacteria; estrogen therapy stabilizes hormone levels; and dermabrasion can treat scarring.
  24. The nurse is caring for an immobile patient being treated for diabetes mellitus and a urinary tract infection. What should be included in a plan of care to prevent pressure ulcers in this patient? (Select all that apply.)

    a.

    Reposition the patient at least every 2 hours.

    b.

    Place the patient on a donut-shaped cushion when sitting.

    c.

    Elevate the head of the bed no more than 30 degrees.

    d.

    Apply moisturizer to the skin after bathing.

    e.

    Massage bony prominences including hips and elbows.

    f.

    Assure that skin is dried carefully and completely after washing.
    ANS: A, C, D, F

    When a patient is immobile, the highest possible level of mobility should be maintained; frequent active or passive range-of-motion exercises should be performed as well as turning according to a written repositioning schedule. If patients are on bedrest, turn and reposition them at least every 2 hours, but preferably more often because ischemia development begins after 20 to 40 minutes of pressure. The head of the bed should not be elevated more than 30 degrees to reduce pressure on the coccyx and to reduce friction and shear damage from sliding down in the bed. After bathing, lubricate the skin with moisturizers to prevent dryness. Donut-shaped cushions should never be used. They create a circle of pressure that cuts off the circulation to the surrounding tissue, promoting ischemia rather than preventing it. Avoid massaging bony prominences or reddened skin areas; research has shown that blood vessels are damaged by massage when ischemia is present or when they lie over a bone.
  25. The nurse is assisting with a community education program on prevention of skin cancer. Which of the following factors should the nurse teach patients may contribute to the development of skin malignancies? (Select all that apply.)

    a.

    Immunosuppressive therapy

    b.

    Exposure to ultraviolet (UV) rays

    c.

    High-fat diet

    d.

    Fair skin

    e.

    Use of sunscreen preparations
    ANS: A, B, D

    The major cause of skin malignancies is overexposure to UV rays, most commonly sunlight. Other factors include being fair skinned and blue eyed; genetic tendencies; history of x-ray therapy; exposure to certain chemical agents (e.g., arsenic, paraffin, coal tar); burn scars; chronic osteomyelitis; and immunosuppressive therapy. High-fat diet is a risk factor for some cancers (colon and breast), but there is no evidence at this time that it contributes to skin cancer. Sunscreen protects against skin cancer.
Author
mayjher
ID
344435
Card Set
chapter 54
Description
skin disorders
Updated