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:
Maintaining good hand hygiene is essential in preventing cellulitis and other infections.
Discouraging hand hygiene is not appropriate advice.
Proper handwashing can help reduce the risk of infection transmission.
Choice B rationale:
The nurse should advise the patient to promptly treat any cuts, wounds, or insect bites to prevent cellulitis.
This is a valid and important preventive measure.
Prompt wound care, including cleaning, disinfection, and covering wounds, can reduce the risk of infection.
Choice C rationale:
Sharing personal items with others is not a safe practice in preventing cellulitis.
Sharing items like towels, razors, or personal care items can increase the risk of bacterial transmission and infection.
The nurse should advise against sharing personal items.
Choice D rationale:
Avoiding a healthy lifestyle can impact an individual's overall health, including their immune system function, which can influence their risk of cellulitis.
However, it's not the primary focus of preventive measures for cellulitis.
The nurse should encourage a healthy lifestyle but also provide specific advice on wound care and hygiene to prevent cellulitis.
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.
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