Nokea
Which of the following causes odor in perspiration?
- A. Sunlight
- B. Bacteria on the skin
- C. Air pollutants
- D. Cloudy environment
Correct Answer: B
Rationale: Perspiration is odorless. An odor develops when perspiration mixes with bacteria on the skin. Sunlight, air pollutants, and a cloudy environment do not cause odor in perspiration.
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The nurse is assessing a client who is hospitalized for dehydration from persistent vomiting. How would the nurse assess that the client's skin turgor is related to the state of dehydration?
- A. When the nurse pinches up skin of the hand, there is rapid recoil.
- B. The client has wrinkles of the chest.
- C. The nurse grasps the skin over the sternum between the thumb and forefinger with slow recoil observed.
- D. The nurse grasps the skin over the sternum between the thumb and forefinger with rapid recoil observed.
Correct Answer: C
Rationale: Poor skin turgor, indicated by slow recoil when the skin over the sternum is pinched, suggests dehydration. Rapid recoil indicates normal hydration. Wrinkles on the chest are not a specific indicator of dehydration.
An older adult client is prescribed a topical antifungal medication to treat a skin infection. The client comes back to the clinic in 7 days and informs the nurse that the treatment was not effective. What does the nurse know can occur in the older adult client with topical drugs?
- A. Age-related changes to the skin could decrease the absorption of topical drugs.
- B. Older adult clients are often not compliant with medication administration.
- C. The drug absorption is increased and does not give the medication time to work on the skin infection.
- D. The bacteria may be resistant to the medication.
Correct Answer: A
Rationale: Age-related changes in topical drugs may be altered and therefore decrease the ability to absorb the topical antifungal cream. Older adults are no less compliant than any other age group. Drug absorption would be decreased. The skin infection is related to a fungus, not a bacterium.
A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination using ultraviolet light can be used to determine if the rash is a fungal rash?
- A. Skin biopsy
- B. Fungal culture
- C. Potassium hydroxide test
- D. A Wood light examination
Correct Answer: D
Rationale: A Wood light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light; the others use skin scrapings.
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
- A. Macule
- B. Vesicle
- C. Pustule
- D. Cyst
Correct Answer: C
Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
The nurse is performing a skin assessment on a client that is admitted to the hospital and observes an area over the left heel that is reddened but intact. How would the nurse stage this pressure sore?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: A
Rationale: Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.