Nokea
The nurse is assessing a new patient at the outpatient clinic and notes dry, scaly skin; thin hair; and thick, brittle nails. Which of the following actions is best for the nurse to take at this time?
- A. Instruct the patient about the importance of nutrition in skin heath.
- B. Make a referral to a podiatrist so that the nails can be safely trimmed.
- C. Consult with the health care provider about the need for further diagnostic testing.
- D. Teach the patient about using moisturizing creams and lotions to decrease dry skin.
Correct Answer: C
Rationale: The patient has clinical manifestations that could be caused by systemic problems or interferences with nutrition (e.g. protein deficiency) so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist also may be needed, but the priority is to rule out underlying disease that may be causing these manifestations.
You may also like to solve these questions
The nurse is assessing a patient's scalp and suspects the presence of pediculosis when which of the following assessment findings are observed?
- A. Ringlike rashes with red, scaly borders over the entire scalp
- B. Papular, wheal-like lesions with white deposits on the hair shaft
- C. Patchy areas of alopecia with small vesicles and excorated areas
- D. Red, hive-like papules and plaques with sharply circumscribed borders
Correct Answer: B
Rationale: Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.
The nurse is caring for a patient who is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. Which of the following actions would the nurse plan to implement to minimize complications from this procedure?
- A. Cleanse the skin carefully with an antiseptic soap.
- B. Shield any unaffected areas with lead-lined drapes.
- C. Have the patient use protective eyewear while receiving PUVA.
- D. Apply petroleum jelly to the areas surrounding the psoriatic lesions.
Correct Answer: C
Rationale: The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.
The nurse is teaching a patient with contact dermatitis of the arms and lower legs about ways to decrease pruritus. Which of the following information would the nurse include in the teaching plan? (Select all that apply.)
- A. Cool, wet cloths or dressings can be used to reduce itching.
- B. Take cool or tepid baths several times daily to decrease itching.
- C. Add oil to your bath water to aid in moisturizing the affected skin.
- D. Rub yourself dry with a towel after bathing to prevent skin maceration
- E. Use of an over-the-counter (OTC) antihistamine with sedative effects can reduce scratching.
Correct Answer: A,B,E
Rationale: Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.
The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority?
- A. The patient complains of incisional pain.
- B. The patient 's heart rate is 110 beats/minute.
- C. The patient is unable to detect when the eyelids are touched
- D. The skin around the incision is pale and cold when palpated.
Correct Answer: D
Rationale: Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. Warm, pink skin that blanches with pressure indicates that adequate circulation is present in the surgical area. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 may be related to the stress associated with surgery, assessment of other vital signs and continued monitoring are appropriate. Because local anaesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.
To decrease the risk for sun damage to the skin, which information should the nurse include when teaching patients?
- A. Waterproof sunscreens will provide good protection when swimming.
- B. Use a sunscreen with an SPF of at least 8-10 for adequate protection.
- C. Try to stay out of the sun between the hours of 10:00 and 16:00.
- D. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
Correct Answer: C
Rationale: The risk for skin damage from the sun is highest with exposure between 10:00 and 15:00 during regular time and 11:00-16:00 during daylight savings time. The term waterproof is misleading; no sunscreen is completely waterproof. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.