Nokea
A client recently received lip and tongue piercings and subsequently developed a superinfection of candidiasis from the antibacterial mouthwash. What would the nurse recommend for this client?
- A. Use an antifungal mouthwash or salt water.
- B. Use a soft-bristled toothbrush.
- C. Rinse the mouth after eating food.
- D. Move the piercing back and forth during washing.
Correct Answer: A
Rationale: The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse the mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.
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The nurse is assessing four clients in the skin clinic for skin cancer. Which client is of highest risk for skin cancer?
- A. The client who tans easily
- B. The client with dark-colored skin
- C. The client with psoriasis
- D. The client with scar tissue
Correct Answer: D
Rationale: The nurse is correct to identify that clients with scar tissue are prone to malignant changes of the skin. Fair-skinned clients or those with decreased melanin are at a higher risk for skin cancer. A client with psoriasis is not at an increased risk for skin cancer.
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.
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 an older adult client who has developed chapped and itchy skin. Which nursing intervention included in this client's plan of care should the nurse alter?
- A. Use of a gait belt for ambulation
- B. Maintenance of foam pad on wheelchair
- C. Daily bathing with warm-hot water
- D. Applying lanolin ointment
Correct Answer: C
Rationale: When the client develops dry and itchy skin, the nurse should alter the client's plan of care with respect to bathing. Hot water will dry the skin further. Due to a decrease in epidermal replacement rates, excessive drying of an older person's skin can lead to pruritus, dryness, and infection. Lanolin ointment is good to apply to dry skin because it helps moisturize so this should be kept in the plan. The nurse would not alter the plan of using a gait belt for ambulation or using a foam pad on the wheelchair.
The nurse is caring for a client with a suspicious lesion on the client's head. The lesion is sore and resembles basal cell carcinoma. Which client finding is a risk factor for developing skin cancer?
- A. The client is a 2 pack/day cigarette smoker.
- B. The client has androgenetic alopecia.
- C. The client frequently works wearing hats.
- D. The client has a history of cystic acne.
Correct Answer: B
Rationale: The nurse is correct to identify that the client with androgenetic alopecia or male pattern baldness is at risk for skin cancer. Due to the skin being exposed to the ultraviolet radiation of the sun, the client is at risk for malignant skin changes. Smoking cigarettes is a risk factor for many other types of cancer. Wearing hats and having acne is not a risk factor for skin cancer.