Chapter 54. Nursing Care of Patients With Skin Disorders My Nursing Test Banks

Chapter 54. Nursing Care of Patients With Skin Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient admitted to the hospital from a nursing home has a stage 3 pressure ulcer. What is the best way for the nurse to initially document the appearance of the wound?
a. Use objective terminology.
b. Take a photograph of the wound.
c. Use a ruler to accurately measure wound size.
d. Use a clock analogy to describe wound location.
____ 2. The nurse is monitoring a patients stage 3 pressure ulcer for healing during treatment. Which finding indicates that the nursing interventions have been effective?
a. There is a hard crust over the wound.
b. The patient states that pain is minimal.
c. The wound drainage is serosanguinous.
d. The wound has a grainy, spongy texture.
____ 3. A patient has a pressure ulcer that has purulent drainage, areas if black material, foul smelling, and painful. What should the nurse do first for healing to occur?
a. Wound culture
b. Wound dbridement
c. Topical antibiotic administration
d. Intravenous antibiotic administration
____ 4. A patients pressure ulcer is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline and has 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
____ 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 registered nurse (RN) immediately?
a. Patient report of pain
b. Yellow wound drainage
c. A reddened area adjacent to the ulcer
d. Pink grainy appearance at wound edges
____ 6. While caring for a patient with a pressure ulcer the home care nurse teaches the family how to describe the wound to health care providers (HCPs) using colors. What color should the nurse instruct that describes an infected wound?
a. Red
b. Gray
c. Black
d. Yellow
____ 7. The home care nurse is teaching a family how to describe a pressure ulcer to HCPs using colors. What color should the nurse use to describe a pressure ulcer with eschar?
a. Red
b. Gray
c. Black
d. Yellow
____ 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, what should the nurse understand is the patients risk level for developing a pressure ulcer?
a. Low
b. High
c. Minimal
d. Moderate
____ 9. The nurse is cleansing a patients infected pressure ulcer. What type of equipment should the nurse use?
a. A needleless 30-mL syringe
b. A needleless 60-mL syringe
c. A 10-mL syringe with a 24-gauge needle
d. A 30-mL syringe with an 18-gauge needle
____ 10. The nurse is teaching a patient skin care to prevent cancer. Which time of day should the patient instruct 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.
____ 11. The nurse is assessing a patient with pemphigus. What skin manifestations should the nurse expect to observe?
a. Rash
b. Bullae
c. Wheals
d. Vesicles
____ 12. The nurse is participating in planning care for a patient with pemphigus. What nursing diagnosis should the nurse recommend be used to guide this patients care?
a. Risk for Infection
b. Fluid Volume Excess
c. Self-Care Deficit: Skin Care
d. Imbalanced Nutrition: Less Than Body Requirements
____ 13. The nurse is providing care to a patient who has herpes zoster. What nursing diagnosis should the nurse identify as a priority for this patient?
a. Anxiety
b. Acute Pain
c. Risk for Infection
d. Imbalanced Nutrition: Less Than Body Requirements
____ 14. The nurses are reviewing actions to reduce the incidence of infectious skin disorders in patients admitted to the care area. What action should the nurses identify as being the most important to prevent infectious skin disorders?
a. Use antibacterial soap.
b. Wash hands frequently.
c. Use isolation precautions.
d. Sterilize all contaminated objects.
____ 15. The nurse is care for a patient with shingles. Which statement should the nurse include in patient teaching?
a. Herpes simplex 2 causes shingles.
b. Shingles is caused by herpes simplex 1 virus.
c. Varicella zoster is the virus responsible for shingles.
d. Herpes zoster is a virus that is common in older patients.
____ 16. The nurse is caring for a patient with lesions on the skin. Which assessment finding should cause the nurse to suspect scabies?
a. Large, fluid-filled blisters
b. Short, wavy, brownish black lines
c. Reddish brown dots at the base of hairs
d. Gray blue macules on the thighs and axillae
____ 17. The nurse notes that a patient has a honey-colored crust over a thin-walled vesicle. For which infectious skin disorder should the nurse plan care?
a. Scabies
b. Carbuncle
c. Pediculosis
d. Impetigo contagiosa
____ 18. A patient is diagnosed with a benign skin lesion caused by a virus. For which skin condition should the nurse plan care for this patient?
a. Cyst
b. Wart
c. Keloid
d. Pigmented nevi
____ 19. The nurse is planning care for a patient with a malignant skin lesion. Which type of malignant skin lesion should the nurse realize has the poorest prognosis?
a. Lentigo melanoma
b. Nodular melanoma
c. Basal cell carcinoma
d. Squamous cell carcinoma
____ 20. The nurse is caring for a patient with impetigo contagiosa. For which complication should the nurse monitor when caring for this patient?
a. Psoriasis
b. Glomerulonephritis
c. Respiratory infection
d. Basal cell carcinoma
____ 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. You will need to return in 1 week for blood tests for liver function.
b. It is expected that you will experience pain and burning at the treatment sites.
c. You will need to take your psoralen tablets for 1 week following the treatment.
d. Plan to wear dark glasses during the treatment, and for the whole day following treatment.
____ 22. A patient with a carbuncle is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement indicates that further teaching about the care of this skin condition is necessary?
a. Once the swelling and redness are gone, I can stop taking the antibiotics.
b. I should wash the area gently with antibacterial soap before applying a new dressing.
c. Covering my pillow with plastic and cleaning it every day will help prevent additional infection.
d. I will need to increase my fluid and fiber intake to prevent constipation while Im taking the pain medication.
____ 23. A patient with a wound is prescribed wet-to-dry dressings. What should the nurse do prior to performing a dressing change for this patient?
a. Assist the patient to void
b. Medicate the patient for pain
c. Wash hands and apply sterile gloves
d. Moisten the dressing before removing
____ 24. The nurse is assisting a patient with psoriasis apply coal tar to the skin. What action should the nurse anticipate providing after the tar is applied to the patient?
a. Expose the patient UV light.
b. Application of occlusive dressings.
c. Have the patient sit in a warm environment.
d. Provide the patient with 16 ounces of warm fluids.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 25. A patient is prescribed vitamin A acid (Retin-A) as treatment of acne vulgaris. What should the nurse instruct the patient about the purpose of this medication? (Select all that apply.)
a. It decreases scarring.
b. It loosens pore plugs.
c. It kills bacteria in follicles.
d. It stabilizes hormone levels.
e. It stimulates the immune system.
f. It prevents occurrence of comedomes.
____ 26. 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. Apply moisturizer to the skin after bathing.
b. Reposition the patient at least every 2 hours.
c. Elevate the head of the bed no more than 30 degrees.
d. Massage bony prominences including hips and elbows.
e. Place the patient on a donut-shaped cushion when sitting.
f. Assure that skin is dried carefully and completely after washing.
____ 27. The nurse is assisting with a community education program on prevention of skin cancer. Which factors should the nurse teach patients that may contribute to the development of skin malignancies? (Select all that apply.)
a. Fair skin
b. High-fat diet
c. Immunosuppressive therapy
d. Use of sunscreen preparations
e. Exposure to UV rays
____ 28. The nurse is planning care for an older patient to prevent skin breakdown. Which actions should be included in this patients plan of care? (Select all that apply.)
a. Bathe daily with soap and water.
b. Examine skin for areas of breakdown or redness.
c. Remind to change positions on a regular schedule.
d. Apply alcohol-based solution to skin after bathing.
e. Ensure skin is cleansed after episodes of incontinence.
____ 29. The nurse is completing the Braden scale to predict pressure ulcer development risk for a patient on bedrest. Which findings should the nurse score as increasing this patients risk? (Select all that apply.)
a. Eats half of offered foods
b. Patient responds only to painful stimuli
c. Linen must be changed at least once per shift
d. Makes body position changes with assistance only
e. Walks independently outside of the room twice a day
____ 30. The nurse is planning care for a patient with dermatitis. What interventions should be included in this patients plan of care? (Select all that apply.)
a. Pat the skin dry after bathing
b. Apply cool moist compresses
c. Encourage a high-protein diet
d. Provide skin care first thing in the morning
e. Keep fingernails short to prevent scratching

Chapter 54. Nursing Care of Patients With Skin Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: B
Be sure to document with photographs all pressure ulcers present on admission to the hospital. A photograph is objective and easy to use as a baseline to monitor wound healing progress. A. C. D. 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.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application

2. ANS: D
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. A hard crust indicates eschar, which must be removed for healing to occur. C. Serosanguinous drainage indicates absence of infection, not healing. B. Minimal pain is a good outcome but is not a measure of healing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Evaluation

3. ANS: B
Dbridement of nonviable tissue is necessary if there is an open wound. Dbridement removes drainage and wound debris and permits granulation of tissue. A. C. D. After the wound is debrided the need for culture and additional treatment may be determined.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

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. A. Skin is still intact in stage 1. B. Stage 2 is shallow. D. Stage 4 has damage to muscle and bone.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

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

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

6. ANS: D
Pressure ulcers may be described according to a three-color system. Yellow wounds have exudate and are infected. C. Black wounds indicate necrosis. A. Red wounds are pink or red and are in the healing stage. B. Gray is not a color used to describe a wound.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

7. ANS: C
Pressure ulcers may be described according to a three-color system. Black wounds indicate necrosis. Eschar is a black or brown hard scab or dry crust that forms from necrotic tissue. D. Yellow wounds have exudate and are infected. A. Red wounds are pink or red and are in the healing stage. B. Gray is not a color used to describe a wound.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

8. ANS: B
The patient is very thin and is immobile, which makes the patient high risk for developing a pressure ulcer. A. C. D. This patients risk is not low, minimal, or moderate.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

9. 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. C. A smaller needle can generate too much pressure and damage new tissue. A. B. A needleless syringe may not generate enough pressure.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

10. ANS: C
If exposure to the sun is necessary, exposure should be avoided during its highest intensity (10 a.m. to 4 p.m.). A. B. The sun is less intense during these hours. D. The sun remains intense during these hours however the patient also needs to avoid the sun between the hours of 10 am and 2 pm.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

11. ANS: B
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. C. Wheals are usually allergic in origin. D. Vesicles are smaller fluid-filled lesions. A. Rash is a more general term.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

12. ANS: A
The major complication of pemphigus is a secondary bacterial infection. C. D. Nutrition and self-care deficit would be determined based on assessment findings. B. Fluid volume deficit would be more likely than excess because of the oozing blisters.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

13. 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. C. The patient already has an infection. A. D. Anxiety and nutrition diagnoses would be based on assessment.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

14. 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. A. C. D. These actions are not the most important to reduce the development of infectious skin disorders.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

15. ANS: C
Herpes zoster, or shingles, is caused by the varicella zoster virus. B. Herpes simplex 1 causes cold sores. A. Herpes simplex 2 causes genital herpes. C. This disease occurs most commonly in older patients or in those who have a diminished resistance, such as the patient with AIDS, the patient on immunosuppressant agents, or the patient with a malignancy or injury to the spine or a cranial nerve.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

16. ANS: B
The scabies parasite burrows into the superficial layer of the skin. These burrows appear as short, wavy, brownish black lines. C. Pediculosis pubis causes black or reddish brown dots (lice excreta) at the base of hairs or in underclothing. D. Gray blue macules may also be noted on the trunk, thighs, and axillae; this is the result of the insects saliva mixing with bilirubin. A. Large, fluid-filled blisters occur in pemphigus.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

17. ANS: D
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. B. A carbuncle is a boil. A. A scabies rash may appear as small, scattered erythematous papules, concentrated in finger webs, axillae, wrist folds, umbilicus, groin, and genitals. C. Pediculosis causes a papular rash, minute hemorrhagic points, or black or reddish brown dots at the bases of hairs, depending on the type.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

18. ANS: C
Warts are caused by a virus. D. Pigmented nevi are often inherited. C. Keloids are caused by trauma and scarring. A. A cyst is caused by follicle blockage.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

19. ANS: B
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. Nodular melanoma has the least favorable prognosis. A. Lentigo maligna melanoma appears as a slow-growing dark macule on exposed skin surfaces (especially the face) of older patients. The lesion has irregular borders and brown, tan, and black coloring. Prognosis is good if treated in the early stage. C. Basal cell carcinoma arises from the basal cell layer of the epidermis. It is the most common type of skin cancer. D. Squamous cell carcinoma arises from the epidermis. Untreated squamous cell carcinoma can metastasize to distant areas of the body.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential

20. ANS: B
Glomerulonephritis can result from a particular strain of streptococcus infection that causes impetigo. A. C. D. These are not complications of impetigo.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

21. ANS: D
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. A. B. The long-term safety of PUVA therapy is still unknown. Possible side effects include increased skin carcinomas, premature skin aging, and actinic keratosis C. The medication does not need to be taken for 1 week following the treatment.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

22. ANS: A
Antibiotics should be taken for the complete course as ordered. D. Constipation is a potential complication of the prescribed pain medication and preventive measures such as increased fluid and fiber intake are important. B. It is important to cleanse surrounding skin with antibacterial soap, followed by application of antibacterial ointment. C. Cover mattress and pillows with plastic and wipe daily with a disinfectant to prevent spread of infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

23. ANS: B
For wet-to-dry dressings, the wet gauze is placed directly on the wound and allowed to dry completely. The drying process causes the gauze to adhere to the wound; when it is pulled off, tissue is pulled off with it. This results in nonselective debridement because viable tissue may also be removed in this process. These methods are painful, so the patient should be pre-medicated for pain and assessed often. A. The patient does not need to void before the dressing is changed. C. The hands should be washed but sterile gloves are not needed to remove the old dressing. D. Moistening the dressing before removing hinders the intended effect.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

24. ANS: A
Tar preparations may be prescribed for the patient with psoriasis. The tar acts as an antimitotic, slowing the epidermal cell division. Coal tar is commonly used in combination with UV light. B. Occlusive dressings are not used with tars. C. D. There is no need for the patient to sit in a warm environment or to drink warm fluids after the tar is applied.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

25. ANS: B, F
Vitamin A acid (Retin-A, tretinoin) loosens pore plugs and prevents occurrence of new comedones. C. Antibiotics kill bacteria. D. Estrogen therapy stabilizes hormone levels. A. Dermabrasion can treat scarring. E. This medication does not stimulate the immune system.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

26. ANS: A, B, C, 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. E. 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. D. 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.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

27. ANS: A, C, E
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. B. 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. D. Sunscreen protects against skin cancer.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

28. ANS: B, C, E
To prevent skin breakdown, the patients skin should be examined for areas of breakdown or redness, remind the patient to change positions on a regular schedule, and ensure the skin is cleansed after episodes of incontinence. A. Soap and water should not be used to cleanse dry skin. D. Alcohol-based solutions or lotions should be avoided because they dry the skin.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

29. ANS: A, B, C, D
Findings that would increase the patients risk of developing a pressure ulcer include limited intake by only eating half of offered foods, responding only to painful stimuli, moisture necessitating linens to be changed at least once per shift, and unable to change body positions without assistance. E. Walking independently outside of the room twice a day would reduce the patients risk of developing a pressure ulcer.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

30. ANS: A, B, C, E
The patients skin should be patted dry after bathing to prevent further trauma. Cool moist compresses should be applied to relieve inflammation and itching. A high-protein diet promotes healing. Keeping fingernails short helps prevent scratching. D. Skin care should be provided at bedtime to promote comfortable sleep.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

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