Nokea
A patients health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?
- A. Chronic Pain
- B. Impaired Skin Integrity
- C. Impaired Tissue Integrity
- D. Disturbed Body Image
Correct Answer: D
Rationale: Alopecia areata, causing patchy hair loss, often leads to disturbed body image due to its cosmetic impact. It does not cause pain or impair skin/tissue integrity.
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The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
- A. Is anyone in your family allergic to anything?
- B. How long have you had this abrasion?
- C. Do you take any over-the-counter drugs or herbal preparations?
- D. What do you do for a living?
Correct Answer: C
Rationale: Asking about over-the-counter drugs or herbal preparations can identify potential causes of a rash. Family allergy history, occupation, or mislabeling the rash as an abrasion are less immediately relevant.
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
- A. Decreased resistance to ultraviolet radiation
- B. Increased vulnerability to infection
- C. Diminished protection of tissues and organs
- D. Increased risk of skin malignancies
Correct Answer: C
Rationale: Loss of subcutaneous tissue reduces cushioning and insulation for underlying tissues and organs. It does not directly affect UV resistance, infection risk, or malignancy risk.
A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?
- A. Is the rash worse at a particular time or season?
- B. Are you allergic to any foods or medication?
- C. Are you having any loss of sensation in that area?
- D. Is your rash painful?
Correct Answer: B
Rationale: A new rash during antibiotic therapy suggests a possible allergic reaction, which could be life-threatening. Assessing for allergies is the priority over timing, sensation, or pain.
A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?
- A. Has she eaten any new foods today?
- B. Has she bathed in the past 24 hours?
- C. Did she go to a friends house today?
- D. Was she digging in the dirt today?
Correct Answer: A
Rationale: Food allergies are a common cause of urticaria in children. Bathing, visiting friends, or soil exposure are less likely to be relevant triggers.
A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?
- A. Obtain a swab for culture.
- B. Assess the characteristics of the lesion.
- C. Obtain a swab for pH testing.
- D. Apply a test dose of broad-spectrum topical antibiotic.
Correct Answer: B
Rationale: Assessing and documenting the characteristics of an open lesion is the priority to guide further diagnostics or treatment. Culture, pH testing, or antibiotics should follow assessment.