A nurse is conducting an assessment of a patient with a skin infection. Which assessment findings should the nurse prioritize when planning care for this patient?
The patient's ability to ambulate independently.
The size, shape, and characteristics of any skin lesions or blisters.
The patient's response to pain management interventions.
The patient's daily fluid intake.
The Correct Answer is B
Choice A rationale:
"The patient's ability to ambulate independently." While ambulation is an important aspect of patient care, in the context of a skin infection, the priority should be assessing and managing the infection and associated symptoms.
The patient's ability to ambulate independently should be considered but may not be the highest priority.
Choice B rationale:
"The size, shape, and characteristics of any skin lesions or blisters." This is the correct answer.
When assessing a patient with a skin infection, it is essential to prioritize the evaluation of the affected area's skin lesions or blisters.
This assessment can help determine the severity of the infection, whether there are signs of abscess formation, and guide appropriate treatment.
Choice C rationale:
"The patient's response to pain management interventions." While pain management is important, it is a secondary consideration in the context of a skin infection.
Addressing the infection's source and associated complications, such as abscesses, should take precedence.
Choice D rationale:
"The patient's daily fluid intake." While monitoring fluid intake is generally important in patient care, it may not be the highest priority in assessing and managing a skin infection unless there are specific concerns related to hydration status.
The primary focus should be on the infection itself and its associated symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"Skin blisters and abscesses are signs of worsening infection, and we need to adjust your antibiotic therapy." This response is not entirely accurate.
While skin blisters and abscesses can indicate a more severe infection, the immediate response should focus on proper wound care, drainage if necessary, and evaluating the effectiveness of the current antibiotic therapy.
Adjusting antibiotic therapy may be considered later if the infection does not improve.
Choice B rationale:
"Skin blisters and abscesses are common in severe cases of skin infections and may require drainage or further treatment." This response is correct.
Skin blisters and abscesses can occur in severe skin infections, and they often require drainage, wound care, and potentially further medical intervention to address the underlying infection.
Choice C rationale:
"Skin blisters and abscesses are unrelated to your skin infection and may be a separate dermatological issue." This response is not accurate.
Skin blisters and abscesses in the context of a skin infection are likely related to the infection itself and should be managed accordingly.
Choice D rationale:
"Skin blisters and abscesses indicate an allergic reaction to the antibiotic; we will switch to a different medication." This response is not appropriate unless there is clear evidence of an allergic reaction to the antibiotic.
Skin blisters and abscesses are more commonly associated with the severity of the infection or the presence of pus collection, not necessarily an allergic reaction to the medication.
Correct Answer is D
Explanation
Choice A rationale:
"I have blisters all over the area." This statement does not indicate an understanding of the clinical presentation of cellulitis.
Blisters are not a typical symptom of cellulitis.
Cellulitis is characterized by redness, warmth, swelling, and pain, but blisters are more commonly associated with conditions like burns or herpes.
Choice B rationale:
"My skin feels cool to the touch." This statement is not indicative of an understanding of cellulitis.
In cellulitis, the affected area typically feels warm due to inflammation, not cool.
Choice C rationale:
"There is no change in the color of my skin." This statement suggests a lack of understanding of cellulitis.
One of the hallmark signs of cellulitis is a change in skin color, often appearing red or erythematous, in the affected area.
Choice D rationale:
"The area is red, swollen, and painful." This statement correctly indicates an understanding of the clinical presentation of cellulitis.
Cellulitis is characterized by these classic symptoms: redness, warmth, swelling, and pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.