Nokea
A client enters the walk-in clinic stating that there is an itchy, red, warm, raised rash on the left forearm. The nurse documents when the rash developed and what the client was doing when it appeared. Allergic dermatitis is diagnosed. Which instruction is most important to prevent further problems?
- A. Instruct on the use of topical ointment.
- B. Advise against scratching the rash.
- C. Instruct on eliminating further allergen exposure.
- D. Instruct on washing the skin.
Correct Answer: C
Rationale: It is important to instruct on the use of topical ointment, if prescribed, and to keep the area clean and dry. It is also important to advise against scratching the rash. By scratching the itchy rash, the client can open the skin and develop an infection. Staphylococcus aureus is the most common skin infection. To prevent further problems, the client must avoid further exposure to the allergen.
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The nurse has assessed a client's superficial fungal infection that began in the skin between the toes and has spread to the soles of the feet. How would the nurse document this finding?
- A. Tinea corporis
- B. Tinea capitis
- C. Tinea pedis
- D. Tinea cruris
Correct Answer: C
Rationale: Tinea pedis is an infection that begins in the skin between the toes and spreads to the soles of the feet. Tinea corporis is a skin infection of the body. Tinea capitis invades the hair shaft below the scalp. Tinea cruris is a skin infection of the groin.
The nurse is caring for a client with a new tattoo. Which nursing diagnosis is of highest priority?
- A. Altered Skin Integrity
- B. Infection Risk
- C. Acute Pain
- D. Altered Tissue Perfusion
Correct Answer: B
Rationale: The trauma created by a tattoo is similar to a minor burn, thus, skin integrity, pain, and tissue perfusion are not the highest priority. Infection risk is the highest priority due to the injection of ink in the dermis. The priority of care is preventing infection.
The pediatric nurse is instructing a young athlete and parent regarding tinea pedis. Which nursing advice best decreases frequent attacks?
- A. Provide meticulous nail care.
- B. Avoid being barefoot outside.
- C. Avoid white cotton socks.
- D. Rotate shoe use.
Correct Answer: D
Rationale: The nurse is correct to instruct the client to rotate the use of different shoes allowing the shoes time to evaporate shoe moisture from use. The fungus particularly grows in dark, warm, moist areas. Eliminating the factors decreases the risk of further outbreaks. The other options are not necessary.
The nurse is caring for a client with a furuncle. What advice should the nurse give the client to prevent the spread of the infection?
- A. Keep hair short, clean, and away from the face and forehead.
- B. Never pick or squeeze a furuncle.
- C. Avoid the use of cosmetics.
- D. Use tepid bath water.
Correct Answer: B
Rationale: The client with a furuncle should never pick or squeeze it as the drainage is infectious and this practice favors the spread of the infection. Infections by organisms that usually exist harmlessly on the skin surface cause furuncles. Keeping the hair short, clean, and away from the face and forehead, avoiding cosmetics, and using tepid bath water do not help in preventing the spread of a furuncle.
The nurse is caring for a client with possible lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff?
- A. Nits are located near the scalp.
- B. Dandruff is throughout the hair.
- C. Nits are difficult to move from hair shafts.
- D. Dandruff looks white and flakey.
Correct Answer: C
Rationale: The nurse is correct to use the difference of the nits being securely attached to the hair shaft as a guide to confirmation of lice infestation. Dandruff is fine, white particles of dead, dry scalp cells that can be easily picked from the hair.