Nokea
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
- A. Macule
- B. Vesicle
- C. Pustule
- D. Cyst
Correct Answer: C
Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
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Which of the following pigments influences hair color?
- A. Pheromones
- B. Keratin
- C. Seburin
- D. Melanin
Correct Answer: D
Rationale: Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Seburin is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
Which stage of a pressure injury is exhibited by deeply ulcerated tissue, exposing muscle and bone?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV occurs when the tissue is deeply ulcerated, exposing muscle and bones. Stage III pressure sores are those in which the superficial impairment progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of the skin. Stage II pressure sores are red and accompanied by blistering and a shallow break in the skin.
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.
An older adult client is prescribed a topical antifungal medication to treat a skin infection. The client comes back to the clinic in 7 days and informs the nurse that the treatment was not effective. What does the nurse know can occur in the older adult client with topical drugs?
- A. Age-related changes to the skin could decrease the absorption of topical drugs.
- B. Older adult clients are often not compliant with medication administration.
- C. The drug absorption is increased and does not give the medication time to work on the skin infection.
- D. The bacteria may be resistant to the medication.
Correct Answer: A
Rationale: Age-related changes in topical drugs may be altered and therefore decrease the ability to absorb the topical antifungal cream. Older adults are no less compliant than any other age group. Drug absorption would be decreased. The skin infection is related to a fungus, not a bacterium.