Nokea
A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
- A. Risk for Infection Related to Lesions
- B. Impaired Skin Integrity Related to Epidermal Blisters
- C. Disturbed Body Image Related to Presence of Skin Lesions
- D. Acute Pain Related to Disruption in Skin Integrity
- E. Hyperthermia Related to Disruptions in Thermoregulation
Correct Answer: A,B,C,D
Rationale: Pemphigus vulgaris causes blisters, leading to infection risk, impaired skin integrity, pain, and disturbed body image. Hyperthermia is not a concern; hypothermia is more likely.
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A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.
- A. Affects people predominantly in the eastern half of Africa
- B. Affects men more than women
- C. Does not affect children
- D. Cannot infiltrate
- E. Can progress to lymphadenopathic forms
Correct Answer: A,B,E
Rationale: Endemic Kaposis sarcoma is prevalent in eastern Africa, affects men more, and can progress to lymphadenopathic forms. It can affect children and may infiltrate.
A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan?
- A. Use caution when taking nonprescription medications.
- B. Avoid public places until symptoms subside.
- C. Wash skin frequently to prevent infection.
- D. Liberally apply corticosteroids as needed.
Correct Answer: A
Rationale: Nonprescription medications may exacerbate psoriasis, so caution is needed. Psoriasis is not contagious, frequent washing can worsen scaling, and overuse of corticosteroids may cause skin atrophy.
An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this residents plan of care?
- A. Avoid the application of skin emollients.
- B. Apply antibiotic ointment as ordered following baths.
- C. Avoid using hot water during the patients baths.
- D. Administer acetaminophen 4 times daily as ordered.
Correct Answer: C
Rationale: Using tepid water for baths reduces pruritus in older adults with dry skin. Emollients help, antibiotics are unnecessary without infection, and acetaminophen does not address itching.
A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following?
- A. Wrinkles near the lips and eyes
- B. Removal of acne scars
- C. Vascular lesions on the cheeks
- D. Real or perceived misshaping of the eyes
Correct Answer: A
Rationale: Chemical face peeling is effective for wrinkles around the lips, eyes, and forehead. It does not address acne scars, vascular lesions, or eye shape.
A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
- A. Acyclovir (Zovirax)
- B. Benzoyl peroxide and erythromycin (Benzamycin)
- C. Diphenhydramine (Benadryl)
- D. Triamcinolone (Kenalog)
Correct Answer: B
Rationale: Benzamycin gel, combining benzoyl peroxide and erythromycin, is a common topical treatment for acne. Acyclovir treats herpes zoster, diphenhydramine addresses pruritus, and triamcinolone is used for psoriasis.