Nokea
The nurse is caring for a client with a new tattoo. Which nursing diagnosis is of highest priority?
- A. Altered Skin Integrity
- B. Infection Risk
- C. Acute Pain
- D. Altered Tissue Perfusion
Correct Answer: B
Rationale: The trauma created by a tattoo is similar to a minor burn, thus, skin integrity, pain, and tissue perfusion are not the highest priority. Infection risk is the highest priority due to the injection of ink in the dermis. The priority of care is preventing infection.
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The home health nurse is caring for a client with scabies. When instructing on the proper procedure to wash preworn contaminated clothing, which nursing instruction is essential?
- A. Use commercial grade laundry detergent.
- B. Pretreat clothing where scabies contact existed.
- C. Wash clothes through two laundry cycles.
- D. Use hot water throughout wash cycle.
Correct Answer: D
Rationale: The nurse is correct to instruct the client to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial-grade laundry detergent; the clothing does not need pretreated nor washed through two cycles.
The nurse is assessing a client experiencing an exacerbation of plaque psoriasis. The nurse assesses the area and documents a proliferation of which cell type?
- A. Dermal
- B. Epidermal
- C. Endothelial
- D. Epithelial
Correct Answer: B
Rationale: The nurse is correct to document that the proliferation of skin cells occurs in the first layer of skin cells, the epidermis. In the epidermal layer, there is rapid turnover of the cells. The dermis is under the epidermis. Endothelial is the layer on the inside such as the interior of the blood vessel. Epithelial are on the outside or coating of walls.
A client asks the nurse what psoriasis is. What is the best answer?
- A. It is a chronic, infectious inflammatory disease.
- B. It is characterized by patches of redness covered with silvery scales.
- C. A cure is possible with prompt treatment.
- D. The onset typically occurs in young children.
Correct Answer: B
Rationale: Psoriasis is characterized by patches of erythema covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. It is a chronic non-infectious inflammatory disease. Psoriasis has no cure. The onset is in young- and middle-adulthood.
A client recently received lip and tongue piercings and subsequently developed a superinfection of candidiasis from the antibacterial mouthwash. What would the nurse recommend for this client?
- A. Use an antifungal mouthwash or salt water.
- B. Use a soft-bristled toothbrush.
- C. Rinse the mouth after eating food.
- D. Move the piercing back and forth during washing.
Correct Answer: A
Rationale: The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse the mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.
The nurse is assessing four clients in the skin clinic for skin cancer. Which client is of highest risk for skin cancer?
- A. The client who tans easily
- B. The client with dark-colored skin
- C. The client with psoriasis
- D. The client with scar tissue
Correct Answer: D
Rationale: The nurse is correct to identify that clients with scar tissue are prone to malignant changes of the skin. Fair-skinned clients or those with decreased melanin are at a higher risk for skin cancer. A client with psoriasis is not at an increased risk for skin cancer.