Nokea
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.
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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 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.
A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?
- A. Recent wound assessment, including size and appearance
- B. Insurance information for billing and coding purposes
- C. Complete health history and physical assessment findings
- D. Resources available to the client for wound care supplies
Correct Answer: A
Rationale: The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
- A. A 44-year-old prescribed IV antibiotics for pneumonia
- B. A 26-year-old who is bedridden with a fractured leg
- C. A 65-year-old with hemiplegia and incontinence
- D. A 78-year-old requiring assistance to ambulate with a walker
Correct Answer: C
Rationale: Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
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.