Chapter 27: Care of Patients with Skin Problems (1/29) – Flashcards

B. The infected area should be covered with a clean, dry bandage. Rationale A. The client should shower rather than take a tub bath using an antibacterial soap. B. The infected area should be covered with a clean, dry bandage to prevent the spread of infection. C. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. D. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

A. Massages bony prominences Rationale A. Massaging bony prominences should be avoided in older adult clients. B. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. C. The client should be repositioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. D. Using a moisturizing lotion is appropriate.

A. Lift hips off the chair at least every 30 minutes Rationale A. Lifting hips off the chair at least every 30 minutes relieves pressure and can prevent pressure ulcers. B. Eating a low-fat diet is not a daily prevention strategy for skin integrity. C. Reddened areas should never be massaged. D. Pressure mapping is not a daily activity and is not performed by the client.

C. Clean the client. Rationale A. Applying a barrier cream is not the priority in this situation. B. Assessing the area is not the priority in this situation. C. Cleaning and drying the client is the first priority for skin protection. D. Placing the client in a side lying position is not the priority in this situation.

C. Pressure ulcer development Rationale A. Anemia has no correlation with this client's protein deficiency. B. The client does not have an indicated wound. C. This client is at risk for pressure ulcer if he or she remains bedridden. D. Weight gain has no correlation with this client's protein deficiency.

D. Perform a total skin self-examination monthly with a partner. Rationale A. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. B. Avoiding sun exposure is a primary prevention. C. A person is physically unable to assess all the skin surfaces of his or her body. D. Performing a monthly total skin self-examination with another person is the best secondary preventive measure.

A. "Avoid sun exposure between 11 AM and 3 PM." Rationale A. The sun's rays are strongest between 11 AM and 3 PM and can cause more damage during this time. B. Skin should be examined at least monthly. C. Opaque clothing should be worn to protect the skin from the sun. D. The rays in tanning beds are just as harmful to skin as the sun's rays.

C. "Keep the site covered with a bandage." Rationale A. Frequent handwashing is not the best suggestion in this case. B. Keeping the child isolated from the other children in school is not necessary. C. Keeping the site covered prevents spread of the infection. D. Keeping the child out of school is not necessary.

C. Determines whether the client can reach the affected area Rationale A. The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. B. A demonstration is a good start, but it does not assess the client's ability to perform the task himself. C. Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home. D. Providing dressing materials is a good start, but it does not assess the client's ability to perform the task himself.

C. Infuse over 60 minutes. Rationale A. Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger thrombophlebitis; it should not be given by bolus. B. Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger thrombophlebitis; it should not be given by IV push. C. Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes. D. Vancomycin (Lyphocin, Vancocin) should not be mixed with the primary IV bag. It is administered IV piggyback or through a saline or heparin lock.

A. Changes the dressing frequently Rationale A. Frequent dressing changes help the client feel clean. B. A diet high in protein would not be directly helpful for this client. C. Whirlpool therapy may not be appropriate for this client. D. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

A. Encourages participation in care of the wound Rationale A. Encouraging participation in wound care gives the client a sense of autonomy. B. Encouraging visitors is not the best suggestion for this client. C. By telling the client that she understands his feelings, the nurse not only fails to address the underlying issue but also is patronizing. D. Assuring the client that everything will be all right not only fails to address the underlying issue but also may be untrue.

B. Second Rationale A. First intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. B. Second intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. C. Third intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. D. There is no such thing as mixed intention healing.

A. Hyperbaric oxygen Rationale A. Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers. B. Nutrition therapy can be implemented for all types of wound healing. C. Topical growth factors are typically used for clean, surgically débrided chronic wounds. D. Vacuum-assisted wound closure is typically used with chronic ulcers.

C. Promote mobility and/or frequent repositioning. Rationale A. Reddened areas should never be massaged. B. Padding the ulcer may not be appropriate. C. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer. D. An egg crate mattress may be suggested but is not the best option.

D. Serum albumin Rationale A. Calcium readings do not relate to successful pressure ulcer management. B. Hematocrit readings do not relate to successful pressure ulcer management. C. Increased numbers of immature WBCs do not relate to successful pressure ulcer management. D. Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.

A. "A tanning bed will supply the ultraviolet light I need." Rationale A. Ultraviolet (UV) radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching. B. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. C. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. D. Stress can exacerbate psoriasis.

C. "I should practice good handwashing technique." Rationale A. Warm climates are helpful for psoriatic clients. B. Psoriasis is not contagious. C. Infections such as strep throat can exacerbate psoriatic flare-ups. Handwashing can help prevent infection. D. Psoriasis cannot be cured.

A. Avoiding or reducing skin exposure to sunlight Rationale A. Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). B. Avoiding tanning beds is significant but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. C. Assessing the skin is a secondary prevention. D. Wearing sunscreen is essential but is not the most important technique.

D. Diphenhydramine (Benadryl) Rationale A. Anthralin (Anthaforte, Drithocreme, Lasan) is indicated for treatment of psoriasis. B. Benzyl benzoate (Ascabiol) is a scabicide indicated for treatment of scabies. C. Calcipotriene (Dovonex) is a synthetic form of vitamin D that is used to treat psoriasis. D. Treatment is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful.

C. Hypertension Rationale A. Depression is not an adverse effect of linezolid (Zyvox). B. Hyperglycemia is not an adverse effect of linezolid (Zyvox). C. Linezolid (Zyvox) constricts blood vessels and may trigger hypertensive crisis. D. Incontinence is not an adverse effect of linezolid (Zyvox).

C. Reposition every 2 hours a client who has had a stroke and is incontinent. Rationale A. Using the Braden scale is an assessment that should be done by licensed nursing staff who have broader education and scope of practice. B. Sterile dressing changes should be done by licensed nursing staff who have broader education and scope of practice. C. The nursing assistant has the education and scope of practice to reposition a client. D. A client should be admitted by licensed nursing staff who have broader education and scope of practice.

B. Young adult who has had rhinoplasty and is swallowing frequently Rationale A. Discharge teaching is important but is not a priority because the client is stable and is not experiencing a postoperative complication that requires immediate attention. B. Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse. C. Controlling pain is important, but this client is not experiencing a postoperative complication that requires immediate attention. D. This client is stable and is not experiencing a postoperative complication that requires immediate attention.

A. Blood pressure is 88/40 mm Hg. Rationale A. Too-rapid administration of clindamycin (Cleocin) can cause shock and cardiac arrest; the client's low blood pressure indicates a need to slow the rate and reassess the client. B. An elevated white blood cell count is an expected finding in a client with bacteremia. C. An elevated temperature is expected in a client with bacteremia. D. An elevated heart rate is an expected finding in a client with bacteremia.

B. "Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time." Rationale A. Wearing pajamas to sleep in, leaving soap on the skin, and bathing in very warm water can contribute to dry skin. Reference: p. 472, Health Promotion and Maintenance B. Clothing that fits tightly and rubs can dry the skin. Prolonged contact with nylon stockings or pantyhose causes or exacerbates dry skin on the legs. Avoiding these clothing items can reduce this dryness. Reference: p. 472, Health Promotion and Maintenance C. Wearing pajamas to sleep in, leaving soap on the skin, and bathing in very warm water can contribute to dry skin. Reference: p. 472, Health Promotion and Maintenance D. Wearing pajamas to sleep in, leaving soap on the skin, and bathing in very warm water can contribute to dry skin. Reference: p. 472, Health Promotion and Maintenance

D. Serum prealbumin concentration of 15.2 mg/dL Rationale Adequate nutrition, especially protein intake, helps promote healthy skin and prevent tissue breakdown. A serum prealbumin concentration less than 19.5 mg/dL indicates inadequate nutrition and a severe protein deficiency. With so little protein, the skin cannot repair itself and is at great risk for injury even with minor trauma.

A. Elevate the client's right foot by placing pillows under the leg from the knee to the ankles. Rationale A. No pressure should be placed on the graft, and care must be taken to ensure it does not move over the wound so the blood vessels can connect the graft with the wound bed. Elevating the area allows better circulation and no pressure. Reference: p. 488, Physiological Integrity B. Although placing the client on the abdomen would eliminate pressure on the heel, having the foot hyperextended would move the graft. Reference: p. 488, Physiological Integrity C. Pressing the graft tightly against the bed would disturb the graft location and compromise circulation. Reference: p. 488, Physiological Integrity D. Assessing circulation is a good thing to do but does not promote graft take. Reference: p. 488, Physiological Integrity

C. Reporting symptoms of infection to the prescriber immediately Rationale Humira suppresses inflammatory and immune responses to some degree. This makes the client more susceptible to infection and may suppress some of the usual manifestations of infection. Together, these actions can allow a minor infection to become more severe very quickly. Any potential infection, no matter how minor, should receive immediate medical attention.

A. Fowler's Rationale Only Fowler's position would make the face less dependent, thus promoting venous return and decreasing swelling.