Ch. 32 Skin Integrity & Wound Care

Question 1

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for
impaired wound healing? (Select all that apply.)

A. Extremes in age
B. Chronic illness
C. Low hemoglobin
D. Malnutrition
E. Poor wound care

Answer 1

B. CORRECT: Diabetes mellitus is a chronic illness that places additional stress on the body’s healing mechanisms.
C. CORRECT: Hgb is essential for oxygen delivery to healing tissues, and this client’s Hgb level is low.
D. CORRECT: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies
in essential nutrients delay wound healing.

Question 2

A nurse is collecting data from a client who is 5 days
postoperative following abdominal surgery. The
surgeon suspects an incisional wound infection and
has prescribed antibiotic therapy for the nurse to
initiate after collecting wound and blood specimens for
culture and sensitivity. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Increase in incisional pain
B. Fever and chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst

Answer 2

A. CORRECT: Expect the client to have pain and tenderness
at the wound site with an incisional infection.
B. CORRECT: Expect the client to have fever
and chills with an incisional infection.
C. CORRECT: Expect the client to have reddened or
inflamed wound edges with an incisional infection

Question 3

A nurse educator is reviewing the wound healing
process with a group of nurses. The nurse
educator should include in the information which
of the following alterations for wound healing by
secondary intention? (Select all that apply.)
A. Stage 3 pressure injury
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area

Answer 3

A. CORRECT: Open pressure ulcers heal by secondary
intention, which is the process for wounds that have
tissue loss and widely separated edges.
E. CORRECT: Open burn areas heal by secondary
intention, which is the process for wounds that have
tissue loss and widely separated edges

Question 4

A client who had abdominal surgery 24 hr ago
suddenly reports a pulling sensation and pain
in their surgical incision. The nurse checks the
surgical wound and finds it separated with
viscera protruding. Which of the following actions
should the nurse take? (Select all that apply.)
A. Cover the area with saline‑soaked sterile dressings.
B. Apply an abdominal binder snugly
around the abdomen.
C. Use sterile gauze to apply gentle
pressure to the exposed tissues.
D. Position the client supine with
the hips and knees bent.
E. Offer the client a warm beverage (herbal tea).

Answer 4

A. CORRECT: Cover the wound with a sterile dressing
soaked with sterile normal saline solution to keep
the exposed organs and tissues moist until the
surgeon can assess and intervene.
D. CORRECT: This position minimizes
pressure on the abdominal area.

Question 5

A nurse is caring for a client who is at risk for
developing pressure injury. Which of the following
interventions should the nurse use to help maintain
the integrity of the client’s skin? (Select all that apply.)
A. Keep the head of the bed elevated 30°.
B. Massage the client’s bony prominences frequently.
C. Apply cornstarch liberally to the skin after bathing.
D. Have the client sit on a gel cushion when in a chair.
E. Reposition the client at least
every 3 hr while in bed.

Answer 5

A. CORRECT: Slightly elevate the head of the client’s
bed to reduce shearing forces that could tear sensitive
skin on the sacrum, buttocks, and heels.
D. CORRECT: Have the client sit on a gel, air, or foam cushion
to redistribute weight away from ischial areas

Question 6

A nurse is providing information about a new
prescription for corticosteroid cream to a client who
has mild psoriasis. Which of the following instructions
should the nurse include? (Select all that apply.)
A. Apply an occlusive dressing after application.
B. Apply three to four times per day.
C. Wear gloves after application
to lesions on the hands.
D. Avoid applying in skin folds.
E. Use medication continuously over
a period of several months.

Answer 6

A. CORRECT: An occlusive dressing can enhance the efficacy
of the topical corticosteroid on the exposed lesions.
C. CORRECT: Gloves worn after the medication can
enhance the efficacy of the topical corticosteroid
on the exposed lesions of the hands.
D. CORRECT: Corticosteroid cream applied to lesions in
skin folds increases the risk of yeast infections

Question 7

A nurse is teaching a client who has a history of
psoriasis about photochemotherapy and ultraviolet
light (PUVA) treatments. Which of the following
instructions should the nurse include in the teaching?
A. Apply vitamin A cream before each treatment.
B. Administer a psoralen medication
before the treatment.
C. Use this treatment every evening.
D. Remove the scales gently following each treatment

Answer 7

B. CORRECT: PUVA treatment involves the administration of
a medication (psoralen) to enhance photosensitivity

Question 8

A nurse is educating a client on the use of
calcipotriene topical medication for the
treatment of psoriasis. Which of the following
laboratory values should the nurse monitor?
A. Potassium
B. Calcium
C. Sodium
D. Chloride

Answer 8

B. CORRECT: Hypercalcemia is a possible
adverse effect of calcipotriene

Question 9

A nurse is providing teaching to the guardian of
a child who has contact dermatitis. Which of the
following information should the nurse include?
A. Use fabric softener dryer sheets when
drying the child’s clothing.
B. Apply a warm, dry compress to the rash area.
C. Place the child in a bath with colloidal oatmeal.
D. Leave the child’s hands uncovered during the night.

Answer 9

C. CORRECT: The use of a colloidal oatmeal
bath will relieve the child’s itching

Question 10

A nurse caring for a client who has contact
dermatitis and has a new prescription for
diphenhydramine. For which of the following
adverse effects should the nurse monitor?
A. Elevated blood glucose levels
B. Anorexia
C. Increased salivation
D. Insomnia

Answer 10

B. CORRECT: Monitor the client for anorexia, which is
a possible adverse effect of diphenhydramine

Question 11

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient’s nursing care plan?

Document the findings and continue to monitor the patient.
Administer antipyretics, as prescribed.
Increase the frequency of assessment to every hour and notify the patient’s primary care provider.
Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

Answer 11

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

Question 12

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply.

Serous drainage is composed of the clear portion of the blood and serous membranes.
Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding.
Purulent drainage is composed of white blood cells, dead tissue, and bacteria.
Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor.
Serosanguineous drainage can be dark yellow or green depending on the causative organism.

Answer 12

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

Question 13

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last.

Notify the health care provider of the situation.
Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
Place the patient in the low Fowler’s position.

Answer 13

c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler’s position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

Question 14

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, “I am so ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?

Pain
Impaired Skin Integrity
Disturbed Body Image
Disturbed Thought Processes

Answer 14

c. Wounds cause emotional as well as physical stress.

Question 15

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

Using sterile dressing supplies
Suggesting dietary supplements
Applying antibiotic ointment
Performing careful hand hygiene

Answer 15

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

Question 16

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.

Hemostasis occurs immediately after the initial injury.
A liquid called exudate is formed during the proliferation phase.
White blood cells move to the wound in the inflammatory phase.
Granulation tissue forms in the inflammatory phase.
During the inflammatory phase, the patient has generalized body response.
A scar forms during the proliferation phase.

Answer 16

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

Question 17

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply.

Enhanced healing due to the presence of sugars and proteins
Delayed healing due to dead tissue present in the wound
Decreased effectiveness of antibiotics against the bacteria
Impaired skin integrity due to overhydration of the cells of the wound
Delayed healing due to cells dehydrating and dying
Decreased effectiveness of the patient’s normal immune process

Answer 17

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

Question 18

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply.

Use standard precautions or transmission-based precautions when indicated.
Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.
Clean the wound in full or half circles beginning on the outside and working toward the center.
Work outward from the incision in lines that are parallel to it from the dirty area to the clean area.
Clean to at least 1 in beyond the end of the new dressing if one is being applied.
Clean to at least 3 in beyond the wound if a new dressing is not being applied.

Answer 18

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

Question 19

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply.

The patient takes time to think about responses to questions.
The patient is 86 years old.
The patient reports inability to control urine.
The patient is scheduled for a hip arthroplasty.
Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL).
The patient reports increased pain in right hip when repositioning in bed or chair.

Answer 19

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

Question 20

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?

“I can expect to have more discomfort in the area where the cold is applied.”
“I should expect more drainage from the incision after the ice has been in place.”
“I should see less swelling and redness with the cold treatment.”
“My incision may bleed more when the ice is first applied.”

Answer 20

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

Question 21

A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record?

A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4

Answer 21

B) Stage 2

A pressure injury is skin damage usually over a bony prominence or from a medical device such as a Foley catheter tubing. A stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin. Risk factors for pressure injuries include poor nutrition-being NPO for 3-5 days, dehydration, low albumin, chemotherapy, steroids, immobility, contractures, past history of pressure injuries, incontinence, diabetes, poor sensory perception, paralysis, and obesity. The Braden Scale is utilized to identify clients at high risk for pressure injuries. The Braden Scale rates clients by sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Question 22

The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply.

A) Pressure redistribution every 1-2 hours
B) Use strong deodorant soaps when bathing
C) Encourage a diet high in protein and calories
D) Keep clients clean and dry by managing incontinence
E) Rub and massage pressure injuries
F) Use moisturizers and creams after bathing

Answer 22

A) Pressure redistribution every 1-2 hours
C) Encourage a diet high in protein and calories
D) Keep clients clean and dry by managing incontinence
F) Use moisturizers and creams after bathing

Question 23

A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment?

A) Stage 1
B) Stage 2
C) Unstageable
D) Deep tissue injury

Answer 23

C) Unstageable

An unstageable pressure injury involves full thickness tissue damage but the wound base of the injury is obscured with yellow, brown, green, tan, or gray stringy slough or tan, black, or brown eschar. Once the slough is removed, the tissue damage will likely be a stage 3 or 4 pressure injury. An unstageable pressure injury is a full-thickness injury where the base of the wound is obscured by extensive slough or necrotic tissue. Debridement must be completed before staging can be performed. Treatment involves sharp, autolytic, enzymatic, or mechanical debridement of the slough or necrotic tissue, offloading the pressure, and adequate nutrition.

Question 24

An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client’s right heel. How should the nurse document her findings?

A) Deep tissue injury
B) Stage 1
C) Stage 2
D) Stage 3

Answer 24

A) Deep tissue injury

A deep tissue injury involves tissue loss to the muscle and appears as a maroon, purple or red injury that may be a blood-filled blister or bulla. The tissue damage may not be visible at first, but the tissue damage is extensive and involves bone, tendon, and ligament. The injury usually appears between 24-48 hours after the damage has occurred. Treatment involves pressure relief strategies, adequate nutrition, such as increased protein and calories, and keeping the injury clean and dry until the blister bursts. If the blister bursts, moist wound healing, pressure relief, and increased protein and calories are required to heal the injury. With any pressure injury, the nurse should avoid massaging the bony prominences.

Question 25

A 70-year-old client arrives in the emergency department. The client’s history included chairfast, paralysis from a diving injury, two stage 3 healed pressure injuries to sacrum and right hip, weight loss of 25 pounds in the past 3 weeks, nausea and vomiting for the past week, and type 2 diabetes for 20 years. If the client’s Braden Scale Score was an 8, what risk would this client have for developing a pressure injury?

A) Mild risk
B) Moderate risk
C) High risk
D) Very high risk

Answer 25

D) Very high risk

The Braden Scale score is a risk assessment tool utilized to quantify the risk level a client has for the development of pressure injuries. The Braden Scale scores: Total score: 15-18 is a mild risk for the development of pressure injuries; Total score: 13-14 is a moderate risk of developing a pressure injury; Total score: 10-12 is a high risk for the development of pressure injuries; and Total score of 9 or less: poses a severe risk for developing a pressure injury. The Braden scale is a scale of 1 to 4 and measures a client’s sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The lower the number on the scale, the higher the risk for skin breakdown.

Question 26

The nurse is assessing the client who has taken antibiotics for a urinary tract infection. The nurse notices that the client’s tongue has a white rash/thickening and his mouth is red and raw. What is the nurse’s priority intervention?

A) Provide mouth care focusing on tongue
B) Provide mouthwash with alcohol to help remove white thickening
C) Notify HCP that client has cancer of the tongue
D) Notify HCO that client has Thrush of the mouth and tongue

Answer 26

D) Notify HCO that client has Thrush of the mouth and tongue

Oral thrush or candidiasis is a fungal infection of the mouth caused by disturbance of the normal flora of the body through medications such as antibiotics, prednisone, or inhaled corticosteroids. Wearing upper dentures where the mouth is dry can also increase the likelihood of oral thrush. The treatment for oral thrush is nystatin suspension. The nurse should teach the client to shake the bottle well due to settling of the medication at the bottom of the bottle. The nurse should instruct the client to remove dentures and soak in the nystatin solution at night. Dentures are full of bacteria and the fungal infection can grow on the dentures. The client should be instructed to continue the nystatin 48 hours after signs/symptoms have subsided. Teach the client to put the nystatin swish and swallow in the mouth, swish a few minutes and then swallow. This will treat the mouth, tongue, and throat for the infection.

Question 27

An 18-year-old client comes to the clinic complaining of an itchy, scaly, circular raised rash with a clear center on his lower abdomen. Which will likely be his diagnosis?

A) Tinea corporis
B) Tinea pedis
C) Tinea capitis
D) Tinea versicolor

Answer 27

A) Tinea corporis

Tinea corporis or ringworm is a fungal infection of the skin. Signs and symptoms include an itchy, scaly, circular raised rash with a clearer center. The name ringworm comes from the circular ring-shaped rash or lesions. Tinea corporis can affect any area of the body except hands, feet, nails, scalp, face, beard, and groin. Tinea corporis is very contagious. It is transmitted most in a moist environment or by sharing, clothing, towels, bedding, and personal items. Treatment includes preventing the spread of ringworm by keeping skin clean and dry. The client should wear loose light-weight clothing during hot humid weather. The client should avoid close contact with other individuals until treatment is completed. Bed linen should be washed to prevent spread to other members of the family.

Question 28

The nurse is caring for a client with tinea pedis. Which interventions should be included in discharge teaching? Select all that apply.

A) Wear nylon socks
B) Soak toes in Burow’s solution
C) Keep toes and feet clean and dry
D) Apply moisturizers daily after bathing
E) Continue to apply antifungals after symptoms have subsided

Answer 28

B) Soak toes in Burow’s solution
C) Keep toes and feet clean and dry
E) Continue to apply antifungals after symptoms have subsided

Tinea pedis, also called athlete’s foot, is a fungal infection of the feet. Athlete’s foot is also a fungal infection that affects a person’s feet from excessive sweating and confinement by tightfitting shoes. Athlete’s foot usually develops between the toes first and includes an itchy, stinging, scaly rash. The nurse should provide the following interventions in discharge teaching to a client with tinea pedis: wear cotton socks, not nylon. Nylon socks hold moisture and fungus loves moist damp places. Cotton socks help absorb the moisture. The client should be instructed to soak toes in Burow’s solution 3-4 times/day. Burow’s solution helps to dry the fluid from blisters and vesicles. Ensure toes and feet are clean and dry. Antifungal medications are ordered and should be administered even when the signs/symptoms subside from the fungal infection.

Question 29

Which of these medications are the most prescribed for psoriasis? Select all that apply.

A) Methotrexate
B) Prednisone
C) Infliximab
D) Etanercept
E) Adalimumab
F) Allopurinol

Answer 29

A) Methotrexate
B) Prednisone
C) Infliximab
D) Etanercept
E) Adalimumab

The medications most prescribed for psoriasis include methotrexate, an antimetabolite. Methotrexate stops folic acid metabolism which stops cellular reproduction in the fastest replicating cells. The fastest replicating cells are in the blood and immune system. Prednisone is a corticosteroid and quickly fights inflammation in the clients with psoriasis. Infliximab, etanercept, and adalimumab are tumor necrosis factor inhibitors and with psoriasis, there is too much tumor necrosis factor that must be blocked therefore, these medications block the cycle of inflammation of psoriasis. All of these medications place the client at high risk for infection because of the client’s immune system being suppressed from each one.

Question 30

A client with a dry, red flaky rough rash on her upper chest and back comes to the dermatology clinic and explains to the nurse that she has psoriasis. As the nurse assesses the areas affected by the rash, the nurse recognizes that psoriasis affects which parts of the body? Select all that apply.

A) Scalp
B) Creases of the body
C) Knees
D) Elbows
E) Buttocks
F) Chest
G) Back

Answer 30

A) Scalp
B) Creases of the body
C) Knees
D) Elbows
E) Buttocks

Psoriasis is an autoimmune disease causing silver plaques and reddening skin with rough raised flat tops that affects the scalp, creases of the body, knees, elbows, and buttocks. The patches resemble dandruff-like scales and may develop into major eruptions that extend over large areas of the skin. Psoriasis can be found on the lower back, legs, face, palms, and soles of the feet but can develop anywhere on the body. A compromised immune system does not cause psoriasis, but the immune system is definitely not working correctly in clients with psoriasis. Common infections such as a respiratory infection or an ear infection can cause psoriasis to flare up.

Question 31

A client arrives at the clinic and the nurse is performing an assessment. The client has silver plaques with reddening skin with rough raised flat tops on the scalp, creases of elbows, knees, and buttocks greater than 1 cm in diameter. The client asks the nurse, “Do I have some kind of fungus growing on my skin? It itches a lot and I am embarrassed to go anywhere.” What is the nurse’s best response?

A) “You have an autoimmune disease called lupus, where the immune system attacks itself.”
B) “You have an autoimmune disease called psoriasis, where the immune system attacks the skin.”
C) “You have an autoimmune lifelong disease where the skin plus connective tissue hardening and contraction called scleroderma.”
D) “You have an autoimmune disease called celiac disease where the small intestine is damaged.”

Answer 31

B) “You have an autoimmune disease called psoriasis, where the immune system attacks the skin.”

Psoriasis is an autoimmune disease that causes rapid cell division in the epidermal cells. The body’s T-cells attack the good cells in the body at such a fast rate that the new cells build up and push to the top of the skin where the skin piles up. This results in silver plaques and reddenning skin with rough and raised flat tops on the scalp and creases of the body including the knees, elbows, and buttocks that are < 1 cm in diameter. Psoriasis is thought to be caused by an irritant that heightens the body’s immune system such as a food allergan, trauma, stress, sickness, or sepsis. Strep throat was found to be a trigger for psoriasis. The skin cells are increased and build up causing dry, itchy skin patches.

Question 32

A 50-year-old client diagnosed with psoriasis is prescribed methotrexate to help prevent the T-cells from attacking the good cells. Which of these interventions should be included in teaching for this client? Select all that apply.

A) Report a fever over 100.3 immediately
B) Avoid crowds and sick people
C) Avoid fresh fruit and flowers
D) Avoid sunlight and moisturizers
E) Report platelet counts of 450,000

Answer 32

A) Report a fever over 100.3 immediately
B) Avoid crowds and sick people
C) Avoid fresh fruit and flowers

The interventions that should be included in teaching the client about the prescribed methotrexate should include: Report fever > 100.3º F or 38º C to the health care provider (HCP) immediately; avoid crowds and sick people; avoid fresh fruits and flowers; report bleeding; and no live vaccines. Methotrexate stops folic acid metabolism which stops cellular reproduction in the fastest replicating cell. The fastest replicating cells are found in blood and the immune system. Infection along with sepsis are the major complications of this medication because it suppresses white blood cells (B & T lymphocytes). Sunlight and moisturizers help with psoriasis and are recommended treatment. Thrombocytopenia (platelets < 100,000 mcL) can cause bleeding so the client should be advised to watch for signs of bleeding and report immediately to the health care provider (HCP).

Question 33

The health department nurse is teaching a group of clients with psoriasis causes, triggers, and risks of the disease. Which of these should be included in her teaching? Select all that apply.

A) Trauma and stress
B) Food allergens
C) Sickness
D) Sunlight
E) Moisturizers

Answer 33

A) Trauma and stress
B) Food allergens
C) Sickness

When teaching clients about causes and risks of psoriasis, the nurse should include trauma and stress, food allergens, sickness, cold, and sepsis. Psoriasis is an autoimmune disorder causing rapid cell division in the edpidermal cells. Arachidonic acid, a polyunsaturated fatty acid, is found in red meat, eggs, and dairy products. Arachidonic acid’s byproducts create psoriatic lesions, so red meats, eggs, and dairy products should be avoided. Strep throat, ear infections, respiratory infections, and the common cold can cause psoriasis to develop. Sunlight and moisturizers are used in the treatment of psoriasis. Antimetabolites, steroids, and tumor necrosis factor inhibitors are medications commonly used to treat psoriasis.