Chapter 27: Care of Patients with Skin Problems Nursing School Test Banks

Chapter 27: Care of Patients with Skin Problems

Test Bank

MULTIPLE CHOICE

1. 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 wont cause infection.

d.

After you bathe, put lotion on before your skin is totally dry.

ANS: D

The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Constricting clothing is not related to dry skin, and antimicrobial soaps are actually more drying than other kinds of soap.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortPersonal Hygiene)

MSC: Integrated Process: Teaching/Learning

2. 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.

ANS: A

The focus of nursing care is to improve client comfort and to prevent injury to the skin from scratching. Keeping nails short will help prevent injury, and keeping them clean will help prevent infection should injury to the skin occur. Extra fluids do not change the sensations felt at the itch receptors. Cotton clothing does nothing to help extreme itching, and skin should be lubricated after bathing before drying off.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

3. 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.

ANS: B

Benadryl is an antihistamine that will decrease itching. For most people, diphenhydramine causes drowsiness. This side effect is intensified when alcohol is also consumed, placing the client at increased risk for injury and falls. Aspirin will not interact with this medication. Sun exposure and timing related to meals should not affect administration of the drug.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

4. 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.

ANS: B

The small, pale pink bumps consist of granulation tissue characteristic of new capillary bed growth (capillary buds)an indication of proper wound healing. The nurse should continue current treatment and assessments. Attempting to remove the bumps in any way can interfere with healing. No reason for culturing the wound or placing the client in isolation is known.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

5. 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 clients movement with bedrest.

c.

Cover the wound with an airtight dressing.

d.

Apply hydrocortisone cream as ordered.

ANS: A

Wounds heal best in tissue that is well oxygenated and hydrated, and is kept free of microorganisms. Ensuring that the client is well oxygenated will help bring oxygen and cellular nutrition to the wound. Covering the wound will deprive the new tissue of nutrition and will not enhance healing. Although the client may need to limit the motion of an affected extremity to avoid further trauma, placing a client on bedrest will lead to complications of immobility. Hydrocortisone cream may decrease itching but will not enhance healing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

6. 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

ANS: B

Any wound left to heal by second intention is an open wound and is at risk for infection. This wound is especially prone to infection owing to its location. The client may have pain and that would need to be addressed, but the risk for infection takes priority. No information indicates that fluid volume is a problem. The client could have a poor body image in this situation, although wounds on the coccyx are not visible to the public. However, the priority in this situation is to prevent infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

7. 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.

ANS: D

Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

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

a.

Document the finding per protocol.

b.

Reassess the client in 3 days.

c.

Increase the clients fluid intake.

d.

Consult with the health care provider.

ANS: D

A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction in Risk PotentialPotential for Alterations in Body Systems)

MSC: Integrated Process: Nursing Process (Implementation)

9. 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

ANS: D

Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if he or she does not move about much, but having two risk factors makes the last option the person at highest risk.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction in Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

10. 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

ANS: C

Alginates are highly absorbent materials that do not damage healthy tissue. They require a top dressing to stay in place. Because this wound is draining heavily, this is the best choice. A wet-to-dry gauze is not used for this type of ulcer. A transparent dressing would hold in the drainage. Dry cotton gauze would quickly become saturated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

11. When getting a client up in a chair, the nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which is the nurses 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.

ANS: C

Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Evaluation)

12. A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the nurse include on this clients 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.

ANS: A

Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes saturated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

13. 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

ANS: A

Hydrophilic dressings draw excessive drainage away from the wound surface, helping to promote healing. The other dressing types are not appropriate for this type of wound.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

14. 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

ANS: A

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 dbridement. Warm water would not be recommended for a client with erythema. A client with urticaria would be instructed to use cool water to decrease inflammation and itching.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation)

15. 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 nurses 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.

ANS: A

This hidden wound may first be observed as a small opening in the skin through which purulent drainage exudes. Applying a transparent film dressing would not help this type of wound to heal. Measuring the reddened area would not assist in determining the actual size of the wound, because internal damage has occurred. Alginate dressings could not be applied if the area were not opened.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

16. 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 nurses 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 dbridement.

ANS: D

A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of dbridement of the necrotic tissue and a possible graft to promote healing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Analysis)

17. 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.

ANS: D

A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

18. 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

ANS: A

A compromised immune system puts a client at greatest risk for infection. Although all the other options might increase the clients susceptibility, the one with the greatest potential impact is being immune compromised.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 479

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

19. 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.

ANS: B

VACs have been associated with serious bleeding complications. All of these interventions are important, but assessing for bleeding takes priority because it enhances client safety.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Intervention)

20. 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.

ANS: B

Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

21. 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

ANS: B

The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

22. 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 clients vital signs.

ANS: B

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

23. 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

ANS: C

A client with an elevated white count should be evaluated for sources of infection. Thin drainage, a decrease in wound size, and pending cultures are not indications that the client may have an infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Planning)

24. A client has been admitted for vacuum-assisted wound closure (VAC) treatment for a chronic leg wound. The clients 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.

ANS: B

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 clients wound.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse assesses the client with which condition first?

a.

Folliculitis

b.

Furuncles

c.

Cellulitis

d.

Stage II ulcer

ANS: C

The client with cellulitis has a generalized infection with Staphylococcus or Streptococcus that involves deep connective tissue. The client with folliculitis has a superficial infection of the upper portion of the follicle, and the client with furuncles has a deeper infection in the hair follicle. A client with a stage II ulcer with no infection is less of a priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Planning)

26. 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

ANS: A

The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. A client with an elevated white count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment. The rash could be caused by several different things.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

27. 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

ANS: B

Herpetic whitlow is a form of herpes simplex infection that occurs in health care personnel who have come into contact with viral secretions. This can be spread to other clients as well, and precautions must be taken. HSV-1 infection is most likely a recurring cold sore. Herpes zoster is caused by the reactivation of a virus dormant in the body. Postherpetic neuralgia occurs after an outbreak of herpes zoster and is not contagious.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 492

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

28. 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.

ANS: B

The most serious common complication in the early postoperative period after skin grafting is failure to engraft. If the pedicle flap demonstrates delayed capillary refill when blanching, perfusion is being compromised. Hemorrhage is not a common complication post skin grafting. Pressure ulcer formation and contracture development would not occur quickly after grafting.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Procedures, and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

29. 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 nurses best intervention?

a.

Ill 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.

ANS: A

Mechanical dbridement can be accomplished using the forceful ejection of tap water from a 35-mL syringe. Soaking in a tub is not essential. The client does not have to travel to the hospital.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 488

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

30. 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.

Ill apply cortisone cream to reduce the inflammation.

b.

I will squeeze the lesion until all pus is removed.

c.

Ill keep my arm down at my side to prevent spread.

d.

I will cleanse the area and apply warm compresses and antibiotic cream.

ANS: D

Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth. Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

31. 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 nurses 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

ANS: D

The clinical manifestations indicate cellulitis, a bacterial tissue infection that can spread rapidly and deeply, especially in a client who has diabetes. Cold compresses would not be effective in allowing the lesion to heal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

32. 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 nurses priority intervention?

a.

Placing the client in a single room

b.

Administering an antihistamine

c.

Assessing for allergies

d.

Applying cold compresses

ANS: A

The clients presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. Cold compresses would not be indicated, and this is not an allergic manifestation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

33. 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 dont 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.

ANS: A

For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Good handwashing is important, but it is not the only consideration. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 490

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

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

a.

At the next family reunion, Im 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.

ANS: B

Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, and the patches will decrease in size with ultraviolet light exposure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

35. Which question does the nurse ask to identify a possible trigger for worsening of a clients 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?

ANS: B

Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

36. The nurse notes that a client who has been using psoralensultraviolet A (PUVA) therapy for psoriasis for 1 month has darkening of the skin. Which is the nurses 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.

ANS: A

Darkening of the skin is an expected and normal response to PUVA therapy. No other intervention is necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Evaluation)

37. 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.

ANS: A

The Centers for Disease Control and Prevention recommend that all adults older than age 60 with healthy immune systems get a dose of Zostavax, the immunization for shingles. Monitoring dryness, applying moisturizer, and providing education on disease transmission are all important, but protecting health via immunizations takes priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Teaching/Learning

38. 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

ANS: B

Grouped vesicles on a reddened base are characteristic of infection with herpes simplex virus 1. Tzanck smear and viral cultures are indicated. Blood cultures would be done only with suspected systemic infection. Swab cultures of pustules in bacterial infections are obtained. Scraping the lesions would be part of the microscopic examination for fungal infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Implementation)

39. 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.

ANS: A

A keloid is a benign, noninfectious overgrowth of a scar resulting from excessive accumulation of collagen and ground substance after skin trauma. Although anyone can form a keloid, the propensity is more common among people with dark skin. This is a benign condition.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 501

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

40. 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

ANS: B

This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

41. 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

ANS: C

Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to red man syndrome), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Reactions/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Intervention)

42. The nurse inspects the site where a clients 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.

ANS: D

This skin reaction is the expected and normal response to cryosurgery. No other intervention is necessary other than continued assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

43. 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?

ANS: B

This lesion has the manifestations of cutaneous anthrax. People at risk for anthrax are farm workers, veterinarians, and people exposed to tanning (of hides) or working with wool. The other questions will not give good information about possible exposure to this disease.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

44. 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?

ANS: C

Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Reactions/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

45. 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)

ANS: D

Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 494

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)

46. 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.

ANS: C

Leprosy is a communicable disease caused by mycobacteria. It is present in most areas of the world, including the United States. It can be controlled with a long course of multiple antibiotics and does not require the client to be isolated.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 509

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

47. 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.

ANS: A

Repeated swallowing followed by belching after rhinoplasty is a sign of postnasal bleeding. This sign should be reported immediately to the surgeon.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Procedures, and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

48. 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.

ANS: C

Research shows that an important factor in compliance with TSSE is having a partner with whom to work while performing the assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Implementation)

49. 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.

Woods lamp examination

d.

Diascopy

ANS: A

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential-Diagnostic Tests)

MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.)

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.

ANS: A, D, F

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Procedures, and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

2. In preparation for a client being admitted with herpes zoster, what does the nurse do? (Select all that apply.)

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.

ANS: B, C, E

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 been vaccinated for it is at high risk for getting chickenpox. It is a disease of immune suppression, so no one who is immune suppressed should be in the same room. It is best to put this client in a private room. Use of gloves and good handwashing are sufficient to prevent spread. It is very painful and requires analgesia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

3. Which preventive measures does the nurse use to prevent skin lesions in older adults? (Select all that apply.)

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.

ANS: A, B

Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin wont tear. Restraining devices may need to be used, but they should not be applied tightly. No contraindication to using whirlpool therapy for the older client is known.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

4. In assessing a clients wound, which finding assists the nurse in determining that the wound is infected? (Select all that apply.)

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.

ANS: C, D, E

A wound that is open can be contaminated but not necessarily infected. Granulation tissue is a healthy response. The presence of inflammation, odor, and exudate is an indication that the wound should be cultured to assess for infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment)

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