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Terms in this set (99)
inflammation of the skin cells
Dead cells and tissues
Black, gray, or brown nonviable, denatured collagen
Pull the wound edges inward along the path of least resistance
Production of new skin cells by undamaged epidermal cells
Remove exudate and dead tissue
The nurse is directing the home health aide in the care of an older adult patient. The patient reports dry skin and wants help in applying an emolient cream. What does the nurse direct the aide to do?
Assist the patient to soak for 20 minutes in a warm bath and then apply the cream to slightly damp skin within 2 to 3 minutes after bathing.
Which patients are at risk for pressure ulcers?
A middle-aged quadriplegic patient who is alert and conversant;
A bedridden patient who is in the late stage of Alzheimer's;
A very heavy patient who must be assisted to move in the bed;
A thin patient who sits for long periods and refuses meals;
The nurse is caring for an obese patient who has been on bedrest for several days. The nurse observes that the patient is beginning to develop redness on the sacral area. What intervention is used to decrease the shearing force?
Place the patient in a side-lying position.
The nurse is reviewing the results of a pressure mapping on a patient at high risk for pressure ulcers. The map shows a red area over the hips. How does the nurse interpret this evidence?
Greater heat production associated with greater pressure.
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has been refusing to eat the hospital food. Which indicator is the most sensitive in identifying inadequate nutrition for this patient?
Prealbumin level of 17.5 mg/dL
Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of the area and sees that the area blanches with pressure. The nurse interprets this finding as changes related to which factor?
Blood vessel dilation
The nurse is assessing a wound on a patient's abdomen. What is the correct technique?
Assess the wound as a clock face with 12 o'clock in the direction of the patient's head and 6 o'clock in the direction of the patient's feet.
The nurse is assessing a patient's wound every day for signs of healing or infection. Which finding is a positive indication that healing is progressing as expected?
Area appears pale pink, progressing to a spongy texture with a beefy red color.
The student nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small opening in the skin with purulent drainage. Which technique does the student use to check for tunneling?
Use a sterile cotton-tipped applicator to probe gently for a tunnel.
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the coccyx with skin intact. These findings suggest which stage of a pressure ulcer?
Suspected deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown, what does the nurse include in the plan of care?
Applying a pressure reduction overlay to the mattress;
Frequent re positioning of the patient;
Using positioning devices to keep heels pressure-free;
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral decubitus?
Wound will show granulation and decrease in size.
A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for which potential complication?
Which class of medication would exclude a patient from participating in negative pressure wound therapy (NPWT)?
A patient on the unit has herpes zoster. Which staff members would be best to assign for the care of this patient?
Staff members who have had chickenpox
The ED nurse is giving discharge instructions to the parents of a child who has been diagnosed with bedbug bites. What instructions does the nurse give to the parents?
Wash linens and clothing in hot water and dry on high heat;
Discard deeply infested furniture or matresses;
Place items that cannot be washed in the sunlight to be heated;
Steam-clean all carpets and curtains.
A patient diagnosed with bedbug bites says to the nurse "I am so embarrassed. I shower daily and do not live in an unclean enviornment." Which response by the nurse is most appropriate?
"Can you tell me what you understand about bedbugs?"
Which statement about palmoplantar pustulosis (PPP) is true?
It is often associated with social and physical disabilities
A mother reports that her child has dry skin with itching that seems to worsen at night. What nonpharmacologic interventions does the nurse teach to the mother?
Keep the child's fingernails trimmed short and filed, to reduce skin damage;
Place mittens or splints on the child's hands at night if the scratching is causing skin tears during sleep;
Read the child a relaxing and familiar story to reduce stress;
Colloidal oatmeal bath may give temporary relief.
After eating a food that triggered an allergic reaction, a patient developed hives. In addition to over-the-counter diphenhydramine (Benadryl), what does the nurse suggest to the patient for self care?
Avoid alcohol consumption which can potentiate the sedative effect of Benadryl.
THe nurse is examining a patient's skin and sees large, sore-looking, raised bumps with pustular heads. Which method does the nurse use to obtain a specimen to test for a bacterial infection?
Take a culture swab of the purulent material.
The nurse is teaching a patient about self-care for a minor bacterial skin infection. What is the most important aspect the nurse emphasizes?
Bathe daily with an antibacterial soap.
A patient is diagnosed with psoriasis vulgaris. Which description of the characteristic lesions of psoriasis would the nurse expect to see in the patient's documentation?
Plaques surmounted by silvery-white scales
What does the treatment of psoriasis include?
UV light therapy;
Calcipotriene (Dovonex) topical cream;
What is the most common symptoms of pruritus?
The nurse is teaching an older adult about how to deal with and prevent dry skin. What information does the nurse include?
Use a room humidifier during the winter months or whenever the furnance is in use;
use a superfatted, nonalkaline soap instead of deodorant soap;
Rinse the soap thoroughly from the skin;
Avoid clothing that continuously rubs the skin, such as tight belts or pantyhose;
Groin (jock itch)
smooth skin surfaces
The nurse is teaching a patient about treatment of pediculosis. What information does the nurse include?
Proper use of topical sprays or creams, such as permehtrin or lindane;
Abstinence of sexual intercourse with infected person;
Washing clothing and bedding in hot water with detergent
The school nurse is examining a child and observes linear ridges in the skin. The child reports intense itching, especially at night. The nurse scrapes the lesion and examines it under a microscope. For which condition should the child be treated?
The nurse discovers a child has tinea capitis. What does the nurse instruct the parents to do?
Refrain from sharing items like combs or hats.
The nurse is assessing the pedicle flap that has been used to cover a patient's wound, and observes a pale flap with delayed capillary filling when blanched. HOw does the nurse interpret this finding?
Inadequate arterial perfusion
A patient returns from surgery with a large graft site on the sacral area. Which task is delegated to unlicensed assistive personnel?
Give the patient a backrub
The nurse is giving discharge instructions to a patient and family who must continue dressing changes and wound care at home. Which point does the nurse emphasize to help the family prevent infection and minimize cost?
Scrupulous handwashing before and after wound care.
The nurse is caring for a 25-year-old patient who recently had a rhinoplasty as part of reconstruction after cancer treatment. The patient is swallowing repeatedly and belching. Whaat does the nurse suspect?
A patient has been prescribed isotrtinoin (Acutane) for a skin condition. What information does the nurse tell the patient about this drug?
It may cause dry, chapped lips;
Strict birth control measures are necessary;
Liver function studies should be monitored while on this therapy.
The nurse is caring for a patient with toxic epidermal necrolysis (TEN). Which nursing action is included in the nursing care plan?
Assessing input and output
A patient is prescribed a topical steroid for treatment of contact dermatitis. Which instruction does the nurse provide to the patient about this drug?
Moisten dressings with warm tap water; place over topical steroids for short periods.
Which statemtent is true about the applications and use of topical preparations?
Using an oil-based ointment in the axillary area could cause folliculitis.
A rash caused by toxic injury to the skin as a result of contact with an irritant substance
A chronic, contagious, systemic mycobacterial infection of the peripheral nervous system with skin involvement
A drug-induced skin reaction that may include a mix of vesicles, erosions, and crusts.
Painless boil-like lesions and eschar that form regardless of treatment used
A rare, chronic blistering disease with high morbidity and mortality
A rare, acute drug reaction of the skin that gradually heals in 2 to 3 weeks with widespread peeling of the epidermis
TOxic epidermal necrolysis
Purple, flat-topped, itchy papules over the wrists and inner surfaces of the forearms
Also known as leprosy
Removed from cosmetic reasons or if a lesion becomes irritated from friction
A lesioin of the sacral area that often has a sinus tract extending into deeper tissue structures
Overgrowth of a scar with excessive accumulation of callagen and ground substance
Mole, a benign growth of the pigment-forming cells
A patient has a partial-thickness wound. How long does the nurse anticipate the healing by epithelialization will take?
5 to 7 days.
A toddler is miserable with itching from chickenpox. Which type of bath is the best to help relieve the toddler's discomfort?
Aveeno collodial oatmeal
The nurse is performing daily wound care and dressing changes on a patient with a full-thickness wound. The patient protests when the nurse attempts to debride the wound. What is the nurses best response?
"Harmful bacteria can grow in the dead tissue and it also interferes with the body's attempt to fill in the wound with new cells and colllagen."
A patient has a stage III pressure ulcer over the left trochanter area that has a thick exudate. The wound bed is visisble and beefy red, and the edges are surrounded with swollen pink tissue. The exudate has an odor. Which dressing is best for this wound?
THe nurse is caring for a patient with arterial insufficiency in the lower right leg. In order to prevent leg ulcers, what does the nurse do?
Places the leg in a dependent position.
The nurse is caring for a patient who had surgical debridement with a skin graft on the leg. The patient returns from the operating room with the graft site immobilized and a bulky cotton pressure dressing in place. What does the nurse do next?
Encourages elevation and complete rest of the grafted area.
The nurse is caring for several patients who are incontinent of stool and urine. Which talk is delegated to unlicensed assistive personnel?
Wash the skin with a pH-balanced soap in maintain normal acidity.
The nurse is caring for a patient in a prolonged coma after a serioius head injury. The nurse uses which intervention to prevent the development of pressure ulcers for this patient?
Use pillows or padding devices to keep heels pressure-free;
Delegate turning and positioning every 2 hours;
Obtain an order for a pressure-relief device.
THe nurse is assessing a patient's skin and observes a superficial infection with a raised, red rash with small pustules. How does the nurse interpret this finding?
A patient has a painful and unsightly herpes simplex blister on her lip, and would like to have her school photo delayed until after the lesion has resolved. How long does the nurse tell the patient the outbreak may last?
3 to 5 days
The nurse is caring for a patient who needs frequent oral hygiene and endotracheal suctioning. In this particular circumstance, the nurse wears gloves to prevent contracting and spreading which organism?
Methicillin-resistant Staphylococcus aureus
The nurse hears in report that a patient admitted for an elective surgery also has herpes zoster. Which factor causes contact isolation to be initiated for this patient?
Fever and malaise are present as accompanying symptoms
A patient is diagnosed with a primary herpetic infection. The nurse questions an order for which drug?
The public health nurse is reviewing case files of people who were exposed and treated for cutaneous anthrax. Which patient who develops the disease warrants further investigation as a possible bioterrorism exposure?
A patient reported painless raised vesicles that itched. Within a few days, there was bleeding in the center and then it sank inwards. Now it looks black and leathery. Which question does the nurse ask in order to elicit more information about this patient's condition?
"Do you work with or around animals?"
A patient underwent cyrosurgery for removal of a small lesion. The nurse teaches the patient to clean the area to prevent infection. What does the patient use for cleaning?
A patient is diagnosed with chronic psoriasis and is prescribed a topical therapy of anthralin (Lasan). What does the nurse teach the patient about proper use of this drug?
Check for local tissue reaction
What does the nurse teach a patient about ultraviolet (UV) therapy for psoriasis?
Wear dark glasses during and after treatment if psiralen is prescribed
Which are examples of benign skin tumors?
Most common cause; ultraviolet exposure; metastasis is rare.
Basal cell carcinoma
Invades locally and is potentially metastic; arises from epidermis
Squamous cell carcinoma
Pigmented skin cancer that is highly metastic
Premalignant lesions of the cells of the epidermis
The nurse is examining the nevi on a patients back and neck. Because about 50% of malignant melanomas arise from moles, which finding is a concern to warrant further investigation?
Sudden report of itching.
Koebner's phenomenon is known as a greater risk for which disorder/condition?
Which statement is true about Moh's surgery used to treat squamous cell carcinoma?
Cure rates are high and there is less removal of healthy tissue compared with other surgical methods.
THe nurse is talking to a patient who is planning to have cosmetic plastic surgery. Which patient statement prompts the nurse to report concerns to the surgeon?
"I know this surgery is going to solve my marital problems."
THe nurse is doing preoperative teaching for a patient who is scheduled to have cosmetic plastic surgery. The nurse decides the surgeon must be notified when the patient adamantly refuses to comply with which instruction?
Stop smoking cigarettes either before or after the procedure.
The nurse is caring for a patient who had facial reconstruction surgery. IN order to decrease pressure in the head region, what does the nurse instruct the patient to do?
Avoid bending over, blowing the nose, sneezing with the mouth closed.
AN older patient who is receiving chemotherapy is diagnosed with toxic epidermal necrolysis. In addition to identifying the causative agent, what does the nurse monitor for?
Fluid and electrolyte imbalance, caloric intake, and hypothermia
The nurse is caring for a patient with localized leprosy who recently immigrated to the U.S. The patient is fearful because she has seen others with leprosy deformity. What is the nurse's best response?
"One or two isolated red plaques suggest that your body has high immunity."
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