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When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?
- A. Impaired Skin Integrity Related to Scaly Lesions
- B. Acute Pain Related to Blistering and Erosions of the Oral Cavity
- C. Impaired Tissue Integrity Related to Epidermal Shedding
- D. Anxiety Related to Risk for Melanoma
Correct Answer: A
Rationale: Psoriasis causes scaly lesions, leading to impaired skin integrity. It does not typically affect the oral cavity, cause epidermal shedding, or increase melanoma risk.
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When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply.
- A. Possible malignancy
- B. Epidermal necrosis
- C. Neurologic involvement
- D. Increased metabolic needs
- E. Possible gastrointestinal mucosal sloughing
Correct Answer: B,D,E
Rationale: High fever, tachycardia, and weakness in TEN indicate epidermal necrosis, increased metabolic needs, and possible GI mucosal sloughing. Malignancy and neurologic involvement are not typical complications.
A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?
- A. After washing, wipe lesions with sterile gauze to remove cellular debris.
- B. Apply antibiotic ointment to lesions after washing.
- C. Apply cornstarch to the patients skin after bathing to facilitate mobility.
- D. Avoid using water to cleanse the patients skin in order to maintain skin integrity.
Correct Answer: C
Rationale: Applying cornstarch after bathing reduces friction and enhances mobility in bullous pemphigoid. Wiping lesions or applying antibiotics is inappropriate, and water can be used for hygiene.
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 public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
- A. Educating participants about the relationship between general health and the risk of skin cancer
- B. Educating participants about treatment options for skin cancer
- C. Educating participants about the early signs and symptoms of skin cancer
- D. Educating participants about the health risks associated with smoking and assisting with smoking cessation
Correct Answer: C
Rationale: Educating about early signs of skin cancer promotes early detection, improving outcomes. General health, treatment options, and smoking are less directly impactful.
A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patients subsequent care?
- A. Teaching the patient to safely and effectively administer immunosuppressants
- B. Helping the patient identify and avoid the offending agent
- C. Teaching the patient how to maintain meticulous skin hygiene
- D. Helping the patient perform wound care in the home environment
Correct Answer: B
Rationale: Identifying and avoiding the irritant is the primary focus for managing contact dermatitis. Immunosuppressants and wound care are not typically required, and hygiene is not the primary issue.