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Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Apply a zinc based cream with brief changes

Apply powder to the perineum

Provide a donut shaped pillow to sit on

Use an antimicrobial soap to clean skin

Place a foam pad on the bed

Ensure the client slides up in bed on their own

Two person assist to move up in bed using slide sheet

Elevate the head of bed above 30 degrees

Request a physical therapy consult

Answer and Explanation

Correct Answer : A,E,G,I

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

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Correct Answer is C

Explanation

A. Brown, rough, greasy, wart-like papules on the face. These describe seborrheic keratosis, a benign skin growth, which is unrelated to overexposure from PUVA therapy.
B. Requires sunglasses because sunlight hurts eyes. PUVA therapy increases sensitivity to light, and clients are advised to wear sunglasses. However, light sensitivity alone does not indicate overexposure. Severe overexposure could cause ocular damage or photokeratitis, but this symptom alone is not diagnostic of excessive treatment.
C. Tenderness upon palpation and generalized erythema. Overexposure to PUVA therapy can cause phototoxic reactions, including skin tenderness, erythema (similar to a sunburn), and blistering. These signs indicate that the client has received too much ultraviolet A (UVA) exposure, requiring treatment adjustments to prevent further skin damage.
D. Thick skin plaques topped by silvery white scales. These are classic symptoms of psoriasis vulgaris and do not indicate overexposure. In fact, PUVA therapy is used to reduce these plaques, not cause them.

A. Shower daily with antibacterial soap. B. Complete full course of antibiotic therapy. C. Refrain from sharing towels and razors with others. D. Eat foods which contain protein and vitamin C. E. Wash hands before and after touching open wounds including

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Shower daily with antibacterial soap (Prevents Future Cellulitis): Keeping the skin clean reduces bacterial load and prevents infections.

Complete full course of antibiotic therapy (Prevents Future Cellulitis & Promotes Healing): Ensuring all bacteria are eradicated helps prevent recurrence and allows the infection to resolve fully.

Refrain from sharing towels and razors (Prevents Future Cellulitis): These items can spread bacteria, increasing the risk of reinfection.

Eat foods rich in protein and vitamin C (Promotes Healing): These nutrients aid in tissue repair and immune function, supporting recovery from cellulitis.

Wash hands before and after touching open wounds (Prevents Future Cellulitis & Promotes Healing): Proper hygiene prevents the spread of bacteria and reduces the risk of secondary infections.

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Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Correct Answer is C

Explanation

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

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The nurse is caring for a young adult who reports uncontrolled acne vulgaris. Which pathological findings should the nurse observe on inspection of skin areas commonly affected in acne vulgaris?

The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important to the community?

The nurse is caring for a one-month-old infant admitted for suspected congenital hypothyroidism. Which diagnostic test results should the nurse report to the healthcare provider?

Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

A nurse develops a delayed hypersensitivity reaction after wearing latex gloves. Which pathophysiologic process is involved in this type of hypersensitive reaction?

The nurse is talking with a couple at a community health fair who ask how cancerous tumors occur. Which pathophysiological process supports the nurse's reponse about cancer cells developement?

Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.