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A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
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A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?
- A. Viral infection: Clindamycin (Cleocin)
- B. Bacterial infection: Acyclovir (Zovirax)
- C. Yeast infection: Linezolid (Zyvox)
- D. Fungal infection: Ketoconazole (Nizoral)
Correct Answer: D
Rationale: Ketoconazole is an antifungal medication appropriate for fungal infections. Clindamycin and Linezolid are antibiotics used for bacterial infections, and Acyclovir is an antiviral drug used for viral infections.
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 is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
- A. Draw blood for albumin, prealbumin, and total protein.
- B. Prepare for and assist with obtaining a wound culture.
- C. Place the client in bed and instruct the client to elevate the foot.
- D. Assess the right leg for pulses, skin color, and temperature.
Correct Answer: D
Rationale: A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.
A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)
- A. Use a lift sheet when moving the client in bed.
- B. Avoid tape when applying dressings.
- C. Avoid whirlpool therapy.
- D. Use loose dressing on all wounds.
- E. Implement pressure-relieving devices.
Correct Answer: A,B,E
Rationale: Using a lift sheet prevents shearing forces, avoiding tape protects fragile skin, and pressure-relieving devices reduce pressure ulcer risk. Whirlpool therapy is not contraindicated, and dressings should be applied as prescribed, not necessarily loose.
A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client?
- A. Punch skin biopsy
- B. Viral cultures
- C. Wood's lamp examination
- D. Diascopy
Correct Answer: A
Rationale: This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates polymorph making skin lesions easier to examine.