Nokea
A patient has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this patients care, the nurse should include which of the following nursing diagnoses?
- A. Risk for Deficient Fluid Volume Related to Excess Sebum Synthesis
- B. Ineffective Thermoregulation Related to Occlusion of Sebaceous Glands
- C. Disturbed Body Image Related to Excess Sebum Production
- D. Ineffective Tissue Perfusion Related to Occlusion of Sebaceous Glands
Correct Answer: C
Rationale: Seborrhea's visible oily skin can lead to disturbed body image. It does not cause fluid volume deficits, thermoregulation issues, or tissue perfusion problems.
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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.
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.
A patient presents at the free clinic with a black, wart-like lesion on his face, stating, Ive done some research, and Im pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?
- A. The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable.
- B. The patients lesion will be closely observed for 6 months before a plan of treatment is chosen.
- C. The patient has one of the few dermatologic malignancies that respond to chemotherapy.
- D. The patient will likely require wide excision.
Correct Answer: A
Rationale: Seborrheic keratosis is benign and requires no treatment unless cosmetically bothersome. It is not malignant, so chemotherapy or excision is unnecessary, and observation is not required.
A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?
- A. Stasis ulcers
- B. Bullous pemphigoid
- C. Psoriasis
- D. Classic Kaposis sarcoma
Correct Answer: D
Rationale: Classic Kaposis sarcoma, common in Jewish men aged 40-70, presents as nodules on the lower extremities. Stasis ulcers, bullous pemphigoid, and psoriasis have different presentations.
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
- A. Wash your face with water and gentle soap each morning and evening.
- B. Before bedtime, clean your face with rubbing alcohol on a cotton pad.
- C. Gently burst new pimples before they form a visible head.
- D. Set aside time each day to squeeze blackheads and remove the plug.
Correct Answer: A
Rationale: Washing with mild soap and water twice daily removes oils and prevents gland obstruction in acne. Alcohol is too harsh, and manipulating pimples or blackheads worsens symptoms.