Exam 2: Chapter 13

Question 1

Which of the following is an important consideration about the skin of an older adult person?

a.
Generous amounts of soap should be used for cleansing.

b.
Sweat gland activity increases.

c.
Skin becomes more vulnerable to damage.

d.
Skin becomes darker in unexposed areas.

Answer 1

C

Question 2

A dermatologist should promptly evaluate which one of the following skin lesions?

a.
Circumscribed, raised area resembling a blob of brown wax

b.
Multicolored raised lesion with a fuzzy border

c.
Bright red, glazed area with satellite lesions around it

d.
Brown spot on the skin with no raised area

Answer 2

B

Question 3

Which topical agent is safe to apply?

a.
Cornstarch to absorb moisture in the groin area

b.
Betadine to disinfect a healing pressure ulcer

c.
An over-the-counter preparation to dissolve a corn

d.
Light mineral oil to moisten skin after bathing

Answer 3

D

Question 4

An older patient complains of dry skin and asks for advice. Which advice should the nurse offer for improving dry skin?

a.
Add oil to the bath water to keep skin soft.

b.
Use tepid bath water.

c.
Move to a climate with lower humidity.

d.
Vigorously dry skin with a rough towel after bathing.

Answer 4

B

Question 5

Which of the following is a true statement about impaired skin integrity?

a.
Stage III pressure ulcer cannot regress to stage II because the subcutaneous tissues regenerate.

b.
Stasis ulcer is another term for pressure ulcer.

c.
Muscle and fat cannot regenerate.

d.
Weight reduction is recommended to help prevent pressure ulcers.

Answer 5

C

Question 6

An older adult woman complains of foot pain from a corn. After assessing her feet, which intervention should the nurse implement to alleviate her discomfort safely?

a.
Cut out an oval corn pad to make a U shape.

b.
Use a corn pad slightly larger than the corn.

c.
Gently remove the corn with a sterile razor blade.

d.
Tape her toe with the corn to the other toes.

Answer 6

A

Question 7

Which of the following is a true statement about skin care for older adults?

a
A licensed practical nurse is qualified to care for the feet of a patient with diabetes.

b.
Onychomycosis is quickly eradicated with antifungal creams or powders.

c.
A ram’s-horn nail should be cut to give a smooth, rounded edge.

d.
Maintaining oral hydration may reduce the incidence of xerosis.

Answer 7

D

Question 8

The nurse plans care to protect the skin covering an older adult’s greater trochanter. Which of the following interventions is the nurse’s priority when the older adult is positioned on the side?

a.
Implement a turning schedule.

b.
Place a cushion between the knees.

c.
Keep the skin clean and dry.

d.
Use the Sims’ position.

Answer 8

A

Question 9

An older adult is vitamin deficient. Which of the following does the nurse offer to the older adult to provide the important missing vitamin for maintaining healthy skin and enhancing tissue repair?

a.
Carrot sticks

b.
Nonfat milk

c.
Orange slices

d.
Unsalted nuts

Answer 9

C

Question 10

The nurse monitors for which clinical indicator when the older adult complains of pruritus?

a.
Coarse skin

c.
Brownish skin

b.
Brown macule

d.
Regional edema

Answer 10

A

Question 11

The nurse cares for an older man who has a malignant melanoma. Which intervention should the nurse implement for this man to prevent a recurrence or advancement of this condition in the future?

a.
Place posters about sunscreen in the halls of his apartment building.

b.
Promote the application of a sunscreen at his neighborhood health fair.

c.
Tell him to schedule all outdoor activities after 4 PM daily.

d.
Instruct him to wear sun-protective clothing and a hat at all times.

Answer 11

D

Question 12

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

Answer 12

ANS: B
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).

Question 13

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.”

Answer 13

ANS: A
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.

Question 14

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

Answer 14

ANS: B
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.

Question 15

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

Answer 15

ANS: A
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.

Question 16

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.

Answer 16

ANS: B
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.

Question 17

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

Answer 17

ANS: A, C, D
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.

Question 18

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

Answer 18

ANS: A, B, C
Pruritus is aggravated by heat, sudden temperature changes, sweating, restrictive clothing, fatigue, exercise and anxiety, perfumed detergents, and fabric softeners.

Question 19

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.

Answer 19

ANS: A, B, D
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.

Question 20

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

Answer 20

ANS: A, B, E
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.

Question 21

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

Answer 21

ANS: A, B, C
The six subscales of the Braden Scale are sensory perception, activity, mobility, moisture, friction and shear, and nutrition.

Question 22

Which infection-control practice should the nurse implement when caring for an older adult who has active herpes zoster?

a.
Wear a face shield and gown for all patient contact.

b.
Instruct the staff and visitors to wear a type of respirator mask.

c.
Use a hospital room that has negative airflow circulation.

d.
Cover ruptured skin lesions with a nonabsorbent dressing.

Answer 22

D

Question 23

The nurse is conducting an admission assessment on an older adult and notes a small lesion with a multicolor appearance. Which assessment approach should the nurse use?

a.
Braden Scale

b.
Wound staging

c.
ABCD (asymmetry, border, color, diameter) rule

d.
Pressure ulcer scale for healing (PUSH) tool

Answer 23

C

Question 24

A nurse will be conducting an educational session on preventing skin cancer at a local senior citizens center. Which should the nurse include in the session?

a.
Squamous cell cancer may appear similar to a wart.

b.
Basal cell carcinoma is more common in women.

c.
Actinic keratosis begins as a pearly papule.

d.
Melanoma is characterized by rough, scaly patches.

Answer 24

A

Question 25

Which nursing intervention is most likely to prevent the creation of an environment conducive to fungal growth?

a.
Provide oral care with soft-bristled brush.

b.
Apply nystatin powder to reddened tissue.

c.
Use mild skin cleansing agents and blot dry.

d.
Apply gauze soaked with antifungal lotion.

Answer 25

C

Question 26

The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 pounds. Which patient information should the nurse use in planning care to reduce this individual’s risk for a pressure ulcer? (Select all that apply.)

a.
Osteoarthritis of neck

b.
Dry mucous membranes

c.
Prealbumin level 7 mg/dl

d.
Fasting glucose 140 mg/dl

e.
Serum sodium 135 mEq/dl

f.
Uses food stamps to get food

Answer 26

B,C,D,F

Question 27

Although intact skin effectively protects an individual, it functions within physiological limits. Which qualities of healthy skin work synergistically within these limits to absorb, cushion against, deflect, or neutralize potentially harmful forces, as well as protect against potentially harmful substances that might impair skin integrity? (Select all that apply.)

a.
Strength

b.
Pliability

c.
Location

d.
Durability

e.
Moistness

f.
Pigmentation

Answer 27

A,B,D

Question 28

Which of the following patient(s) does the nurse identify as at risk for developing fungal infections? (Select all that apply.)

a.
Obesity

b.
Multiple sclerosis

c.
Impaired mental status

d.
Incontinent

e.
Bedridden

Answer 28

A,D,E

Question 29

The nurse identifies which of the following intervention(s) in the treatment of fungal infections? (Select all that apply.)

a.
Eliminate the conditions that created the problem.

b.
Lubricate affected area daily with moisturizing lotion.

c.
Thoroughly clean and dry skin daily.

d.
Use an antibacterial cleanser daily.

e.
Apply miconazole (Micatin) as directed.

Answer 29

A,C,E