Nokea
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.
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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.
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 is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?
- A. Assessment of the patients stool for evidence of intestinal sloughing
- B. Assessment of the patients apical heart rate for dysrhythmias
- C. Assessment of the patients joints for pain and decreased range of motion
- D. Assessment for cognitive changes resulting from neurologic lesions
Correct Answer: C
Rationale: Psoriasis can lead to psoriatic arthritis in up to 30% of cases, necessitating joint assessment for pain and reduced mobility. It does not affect GI, cardiac, or neurologic function.
A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
- A. Assess the drainage in the dressing.
- B. Slowly remove the soiled dressing.
- C. Perform hand hygiene.
- D. Don non-latex gloves.
Correct Answer: C
Rationale: Hand hygiene is the first step in wound care to prevent infection, per standard precautions. Assessing drainage, removing the dressing, and donning gloves follow.
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.