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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.
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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.
After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching?
- A. Low-fat diet with whole grains and cereals and vitamin supplements
- B. High-protein diet with vitamins and mineral supplements
- C. Vegetarian diet with nutritional supplements and fish oil capsules
- D. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
Correct Answer: B
Rationale: The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.
After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs further education?
- A. I'll avoid scratching the patches to prevent worsening.
- B. I'll use moisturizers to keep my skin hydrated.
- C. I'll apply sunscreen to protect my skin from UV damage.
- D. I'll take hot baths daily to soothe the lesions.
Correct Answer: D
Rationale: Hot baths can exacerbate psoriasis by drying out the skin and increasing irritation. The other statements reflect appropriate self-care measures for managing psoriasis, such as avoiding scratching, using moisturizers, and protecting skin from UV damage.
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.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?
- A. Client with blood cultures pending
- B. Client who has thin, serous wound drainage
- C. Client with a white blood cell count of 23,000/mm^3
- D. Client transferred from intensive care with an elevated white blood cell count
Correct Answer: C
Rationale: An elevated white blood cell count, such as 23,000/mm^3, indicates a potential infection. The nurse should evaluate this client for signs of a wound infection, as an elevated white blood cell count is a strong indicator of an infectious process.