13 - Skin Care Flashcards
A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine (Zostavax). Which of the following information should the nurse include in the education?
a. ) Zostavax should only be given to individuals who have never had an episode of herpes zoster (HZ)
b. ) Zostavax is recommended for all individuals over age 60 that have no contraindications to the vaccine
c. ) Zostavax should not be given to anyone with a chronic cardiac or respiratory condition
d. ) Zostavax will always prevent an individual from developing Herpes Zoster
b.) Zostavax is recommended for all individuals over age 60 that have no contraindications to the vaccine
Zostavax is recommended for all persons 60 and older who have no contraindications to the vaccine, including persons with a previous episode of Herpes Zoster (HZ) and those with chronic conditions.
The vaccine does not guarantee that an individual will not get HZ; however, individuals who get the vaccine cut their risk in half and if they do get HZ, it is likely that they will get a milder case.
A nurse is educating a group of nursing assistants in long-term care on the prevention of skin tears. Which of the following interventions should the nurse include in the education? (Select all that apply.)
a. ) Lubricate the resident’s skin with moisturizers twice daily
b. ) Ensure that the resident has adequate nutrition and hydration
c. ) Bathe the resident in hot soapy water
d. ) Avoid the use of lifting shifts when transferring the resident
e. ) Dress the resident in long sleeves and long pants to protect the extremities
a, b, e
a.) Lubricate the resident’s skin with moisturizers twice daily
b.) Ensure that the resident has adequate nutrition and hydration
e.) Dress the resident in long sleeves and long pants to protect the extremities
Soapless bathing, tepid water, and moisturizers twice daily are recommended to prevent skin tears. Heavy soaps and hot water dry out the skin increasing the risk of skin tears. Lifting sheets are recommended as are the use of long sleeves and long pants to protect the extremities.
A nurse assesses a nursing home resident’s pressure ulcer to be a “healing stage III.” The primary reason reverse staging is never used is because:
a. ) even though all tissue layers are replaced as a wound heals, the healed skin is not as strong as it originally was.
b. ) not all tissue layers are replaced as a wound heals, and the healed skin is not as strong as it originally was.
c. ) reimbursement in nursing homes does not allow for reverse staging to be utilized.
d. ) the collagen layer is not replaced during wound healing.
b.) not all tissue layers are replaced as a wound heals, and the healed skin is not as strong as it originally was.
Not all tissue layers are replaced as a wound heals. The wound fills with granulation tissue composed of endothelial cells, fibroblasts, collagen, and extracellular matrix. Muscle, subcutaneous fat, and dermis are not replaced. The healed skin is not as strong as it originally was. Reimbursement in long-term care is not the primary reason for not using reverse staging.
A nurse is assessing an older patient and notes a cluster of fluid-filled vesicles on the right thoracic area. The nurse suspects HZ. The patient asks the nurse, “I really don’t understand how I got shingles. I don’t even know anyone who has this infection.” The nurse includes which of the following in formulating a response to the patient?
a. ) HZ is caused by a reactivation of dormant varicella zoster virus within the sensory neuron of the dorsal root ganglion
b. ) HZ is caused by the same virus as chickenpox and requires exposure to an individual with active chickenpox
c. ) HZ is caused by the same virus as chickenpox and requires direct contact with an individual with HZ
d. ) HZ is caused by the varicella zoster virus and occurs only in individuals who were never previously exposed to the virus
a.) HZ is caused by a reactivation of dormant varicella zoster virus within the sensory neuron of the dorsal root ganglion
HZ is a viral infection caused by a reactivation of the latent varicella zoster virus (the same virus that causes chickenpox) within the sensory neurons of the dorsal root ganglion, decades after the initial varicella zoster infection is established.
HZ is infectious until the lesions are completely crusted over. Individuals do not have to have direct contact with someone who has either chickenpox or HZ in order to have a reactivation; other factors such as illness and stress can cause the reactivation. Individuals who have HZ infection were previously exposed to the varicella zoster virus.
An older patient tells a nurse. “The nurse practitioner told me that these ugly purple bruises on my arms are called purpura and are due to fragile blood vessels. I still don’t understand why this happens to me.” The nurse responds based on the knowledge that: (Select all that apply.)
a. ) purpura is due to normal age-related changes.
b. ) the incidence of purpura increases with age.
c. ) purpura is a precancerous skin condition.
d. ) individuals who take blood thinners are especially prone to purpura.
e. ) individuals prone to purpura should make sure that affected areas are open to the air.
a, b, d
a.) purpura is due to normal age-related changes.
b.) the incidence of purpura increases with age.
d.) individuals who take blood thinners are especially prone to purpura.
Purpura is due to normal age-related changes and hence the incidence increases with age. Individuals who take blood thinners are especially prone to purpura. Purpura is not a precancerous condition. Individuals who are prone to purpura are encouraged to wear protective garments such as long sleeves and long pants.
Which of the following are subscales on the Braden Scale for predicting pressure ulcers? (Select all that apply.)
a. ) Nutrition
b. ) Moisture
c. ) Mobility
d) . Age
e. ) BMI
a.) Nutrition
b.) Moisture
c.) Mobility
The six subscales of the Braden Scale are sensory perception, activity, mobility, moisture, friction and shear, and nutrition.
The nurse is most concerned by observing when assisting with an older client’s bath:
a. ) A firm, irregularly-shaped, pink-colored nodule
b. ) A slightly raised multicolor lesion with an asymmetrical, irregular border
c. ) A pearly papule with prominent blood vessels
d. ) Rough, scaly, sandpaper-like patches that are slightly tender
b.) A slightly raised multicolor lesion with an asymmetrical, irregular border
A slightly raised multicolor lesion with an asymmetrical irregular border is characteristic of melanoma that accounts for less than 5% of skin cancer cases, but it causes most skin cancer deaths.
A firm, irregularly-shaped, pink-colored nodule or persistent red lesion is characteristic of squamous cell carcinoma.
A pearly papule with prominent blood vessels is a characteristic of a basal cell carcinoma.
A tender, rough, scaly, sandpaper-like patch is a characteristic of actinic keratoses (a precancerous lesion).
A nurse is caring for an older adult with xerosis. Which of the following interventions should the nurse include in the patient’s plan of care? (Select all that apply.)
a. ) Encourage adequate fluid intake
b. ) Encourage daily baths of at least 20 minutes
c. ) Maintain a humid environment
d. ) Apply water-laden emulsions to skin immediately after bathing
e. ) Use only deodorant soaps when bathing
a, c, d
a.) Encourage adequate fluid intake
c.) Maintain a humid environment
d.) Apply water-laden emulsions to skin immediately after bathing
Xerosis is extremely dry, itchy skin. Adequate intake of water is essential in rehydrating the skin. Long duration baths or showers should be avoided, and daily bathing may not be needed.
An environment of 60% humidity is recommended. Water-laden emulsions should be applied immediately after bathing. Deodorant soaps should be avoided except in the axilla and groin.
An older person is admitted to the hospital with an exacerbation of congestive heart failure. The nurse notes that the patient complains of severe itching at night and has a red rash on her torso. The patient is diagnosed with scabies. The patient asks the nurse, “How did I get something like this?” The best response by the nurse is:
a. ) “Scabies is highly contagious and spreads easily through physical contact.”
b. ) “Scabies is commonly seen in older adults due to normal age-related changes in the skin.”
c. ) “Scabies is only seen in older adults who have multiple chronic illnesses.”
d. ) “Certain medications can make you more susceptible to contracting scabies.”
a.) “Scabies is highly contagious and spreads easily through physical contact.”
Scabies is caused by a tiny burrowing mite and is highly contagious and easily passed by an infected person to family members and others in close contact by direct physical content. It is not limited to older adults, and age-related changes in the skin do not cause it or make a person more susceptible.
Individuals with multiple chronic conditions are not more likely to develop scabies than other individuals. There is no evidence that medications can make an individual more susceptible.
An older patient complains of pruritus. The nurse suggests which of the following interventions to alleviate the patient’s complaint? (Select all that apply.)
a. ) Use only nonperfumed laundry detergent and fabric softeners
b. ) Avoid sudden temperature changes
c. ) Wear loose-fitting clothing
d. ) Apply heat to affected areas
e. ) Exercise vigorously for at least 30 minutes daily
a.) Use only nonperfumed laundry detergent and fabric softeners
b.) Avoid sudden temperature changes
c.) Wear loose-fitting clothing
Pruritus is aggravated by heat, sudden temperature changes, sweating, restrictive clothing, fatigue, exercise and anxiety, perfumed detergents, and fabric softeners.
