Nokea
When developing the plan of care for a client with a skin lesion requiring topical therapy, which nursing diagnosis would the nurse most likely identify?
- A. Acute Pain
- B. Risk for Infection
- C. Impaired Skin Integrity
- D. Disturbed Body Image
Correct Answer: C
Rationale: Impaired Skin Integrity is the most likely nursing diagnosis due to the presence of a skin lesion requiring topical therapy, as it directly addresses the compromised skin condition.
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After conducting an in-service program for a group of nurses about topical drugs used to treat skin disorders, the presenter determines that the teaching was successful when the group identifies which of the following as an appropriate use for topical enzymes? Select all that apply.
- A. Widespread psoriasis
- B. Chronic dermal ulcers
- C. First-degree sunburn
- D. Severely burned areas
- E. Tinea pedis
Correct Answer: B,D
Rationale: A nurse may apply a topical enzyme to a client with chronic dermal ulcers or severely burned areas. Topical enzymes are not used for widespread psoriasis, first-degree sunburn, or tinea pedis.
Chlorhexidine gluconate is being used in a client for preoperative skin preparation. Which of the following if noted would alert the nurse to a possible adverse reaction?
- A. Taste perversion
- B. Headache
- C. Deafness
- D. Mild erythema
Correct Answer: C
Rationale: The nurse should monitor for deafness as an adverse reaction to the use of chlorhexidine gluconate. Taste perversion, headache, and mild erythema are adverse reactions to penciclovir.
A client is prescribed a topical corticosteroid. The nurse understands that this drug would be contraindicated in which of the following circumstances? Select all that apply.
- A. Monotherapy for bacterial skin infections
- B. Ophthalmic use
- C. Otic use
- D. Monotherapy for widespread plaque psoriasis
- E. Low-potency corticosteroids on the face, groin, or axilla
Correct Answer: A,B,D
Rationale: The use of topical corticosteroids is contraindicated in the following circumstances: known hypersensitivity to the drug or any component of the drug; as monotherapy for bacterial skin infections; high-potency corticosteroids for use on the face, groin, or axilla; for ophthalmic use; and as monotherapy in widespread plaque psoriasis.
After conducting an in-service program for a group of nurses about topical drugs used to treat skin disorders, the presenter determines that the teaching was successful when the group identifies which of the following as an appropriate use for topical enzymes? Select all that apply.
- A. Widespread psoriasis
- B. Chronic dermal ulcers
- C. First-degree sunburn
- D. Severely burned areas
- E. Tinea pedis
Correct Answer: B,D
Rationale: A nurse may apply a topical enzyme to a client with chronic dermal ulcers or severely burned areas. Topical enzymes are not used for widespread psoriasis, first-degree sunburn, or tinea pedis.
A nurse is instructing a client about how to apply the topical medication prescribed. Which of the following would the nurse identify as an appropriate way to remove the drug from the container? Select all that apply.
- A. Finger cot
- B. Clean finger
- C. Tongue blade
- D. Gauze pad
- E. Cotton swab
Correct Answer: A,C,D,E
Rationale: Using a finger cot, tongue blade, gauze pad, or cotton swab ensures hygienic application of the topical medication, minimizing contamination and direct skin contact.