Nokea
A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?
- A. After washing, wipe lesions with sterile gauze to remove cellular debris.
- B. Apply antibiotic ointment to lesions after washing.
- C. Apply cornstarch to the patients skin after bathing to facilitate mobility.
- D. Avoid using water to cleanse the patients skin in order to maintain skin integrity.
Correct Answer: C
Rationale: Applying cornstarch after bathing reduces friction and enhances mobility in bullous pemphigoid. Wiping lesions or applying antibiotics is inappropriate, and water can be used for hygiene.
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A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster?
- A. Prednisone (Deltasone)
- B. Azanthioprine (Imuran)
- C. Triamcinolone (Kenalog)
- D. Acyclovir (Zovirax)
Correct Answer: D
Rationale: Acyclovir, an antiviral, can halt herpes zoster progression if given within 24 hours of eruption. Prednisone, azathioprine, and triamcinolone are not used for herpes zoster treatment.
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
- A. The childs scalp should be monitored for 48 to 72 hours before starting treatment.
- B. Nits may have to be manually removed from the childs hair shafts.
- C. The disease is self-limiting and symptoms will abate within 1 week.
- D. Efforts should be made to improve the childs level of hygiene.
Correct Answer: B
Rationale: Manual removal of nits is often necessary after medicated shampoo for pediculosis capitis. The condition is not self-limiting, requires prompt treatment, and is not caused by poor hygiene.
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.
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?
- A. Impaired Skin Integrity Related to Scaly Lesions
- B. Acute Pain Related to Blistering and Erosions of the Oral Cavity
- C. Impaired Tissue Integrity Related to Epidermal Shedding
- D. Anxiety Related to Risk for Melanoma
Correct Answer: A
Rationale: Psoriasis causes scaly lesions, leading to impaired skin integrity. It does not typically affect the oral cavity, cause epidermal shedding, or increase melanoma risk.
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Dermatofibroma
- D. Malignant melanoma
Correct Answer: D
Rationale: Malignant melanoma often appears as a blue-black lesion with irregular colors and borders. Basal cell carcinoma is waxy with pearly borders, squamous cell carcinoma is scaly and may bleed, and dermatofibroma is a benign, firm nodule.