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A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.)
- A. Have you eaten a large amount of chocolate lately?
- B. Have you been under a lot of stress lately?
- C. Have you recently used a public shower?
- D. Have you been out of the country recently?
- E. Have you recently had any other health problems?
- F. Have you changed any medications recently?
Correct Answer: B,E,F
Rationale: Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
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A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.
A nurse evaluates the following data in a clients chart: 66-year-old male with a health history of cerebral vascular accident and left-side paralysis, white blood cell count: 8000/mm^3, prealbumin: 15.2 mg/dL, albumin: 4.2 g/dL, lymphocyte count: 2000/mm^3, sacral ulcer 4 cm x 2 cm x 1.5 cm. Based on this information, which action should the nurse take?
- A. Consult a dietitian to increase nutritional intake.
- B. Apply a transparent film dressing to the ulcer.
- C. Reposition the client every 4 hours.
- D. Administer antibiotics for wound infection.
Correct Answer: A
Rationale: The prealbumin level of 15.2 mg/dL is low (normal range is typically 15"?36 mg/dL), indicating potential malnutrition, which can impair wound healing. Consulting a dietitian to optimize nutritional intake is the priority to support tissue repair. The white blood cell count is normal, so antibiotics are not indicated. Transparent film dressings are not suitable for deep ulcers, and repositioning should occur more frequently than every 4 hours.
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next?
- A. Turn the mattress overlay to the opposite side.
- B. Do nothing because this is an expected occurrence.
- C. Apply a different pressure-relieving device.
- D. Reinforce the overlay with extra cushions.
Correct Answer: C
Rationale: Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education?
- A. Use lots of moisturizer several times a day to minimize dryness.
- B. Take a cold shower instead of soaking in the bathtub.
- C. Use antimicrobial soap to avoid infection of cracked skin.
- D. After you bathe, put lotion on before your skin is totally dry.
Correct Answer: D
Rationale: The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisturizer in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what dehydrates the skin, it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education?
- A. I can help him shift his position every hour when he sits in the chair.
- B. If his tailbone is red and tender in the morning, I will massage it with baby oil.
- C. Applying lotion to his arms and legs every evening will decrease dryness.
- D. Drinking a nutritional supplement between meals will help maintain his weight.
Correct Answer: B
Rationale: Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.