The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?
Staphylococcus aureus abscess around a hair follicle.
Insect or spider bite that becomes infected.
Sexual contact with an infected partner.
Inadequate blood supply to the area
The Correct Answer is A
A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increase in interstitial osmotic pressure due to cellular damage. A crushing injury damages cells, leading to the release of intracellular proteins and solutes into the interstitial space. This increases interstitial osmotic pressure, drawing fluid from the blood vessels into the injured tissues, causing edema. The inflammatory response further contributes to capillary permeability and fluid leakage.
B. Decrease in interstitial pressures due to low blood pressure. Blood pressure does not directly regulate interstitial pressure in a localized trauma area. Even if systemic blood pressure were low, localized edema can still occur due to tissue damage and increased capillary permeability.
C. Increased intravascular osmotic pressure due to crushing injury. Osmotic pressure in the blood is primarily determined by plasma proteins, such as albumin. A crushing injury does not increase intravascular osmotic pressure; instead, it increases interstitial osmotic pressure, pulling fluid out of the blood vessels.
D. Increased intravascular hydrostatic pressure due to trauma. While trauma can cause localized vascular changes, hydrostatic pressure primarily affects systemic circulation. In this case, localized tissue damage and inflammation—not increased intravascular pressure—are responsible for edema formation.
Correct Answer is ["A","B","C","D","E","G"]
Explanation
A. Immobility. The client requires a walker for mobility and reports difficulty repositioning in bed. Limited mobility increases the risk of pressure injuries due to prolonged pressure on certain areas, reducing blood flow and oxygen delivery to the skin.
B. Obesity. The client has a history of moderate obesity, which increases skin friction, moisture retention, and difficulty with self-care. Excess weight places additional pressure on bony prominences, elevating the risk of pressure ulcers.
C. Inadequate nutritional intake. The client has a poor appetite and decreased oral intake, which can lead to protein and nutrient deficiencies. Poor nutrition impairs skin integrity and delays wound healing, further increasing the risk of pressure injuries.
D. Incontinence. The client wears an incontinence brief due to occasional urinary and fecal accidents. Constant exposure to moisture from urine and stool can break down the skin barrier, making it more susceptible to infections and pressure injuries.
E. Decreased sensory perception. The client reports neuropathy in both hands and lower legs, reducing sensation. Impaired sensation can prevent the recognition of pressure, pain, or injury, leading to delayed intervention and increased risk of skin breakdown.
F. Coarse lung sounds. While coarse lung sounds may indicate respiratory congestion or infection, they do not directly contribute to skin injury risk. This factor is less relevant compared to others affecting skin integrity.
G. Diabetes mellitus. The client has poorly controlled type 1 diabetes, which impairs circulation and delays wound healing. Chronic hyperglycemia can lead to reduced immune response and increased susceptibility to infections and pressure ulcers.
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