Test 4

Question 1

1. Types of drainage (Slide 27)

Answer 1

 Serous: clear, watery plasma
 Purulent: thick, yellow, green, tan, or brown
 Serosanguineous: pale, pink, watery: mixture of clear and red fluid
 Sanguineous: bright red: indicates active bleeding

• #1 way to prevent infection is good hand washing

Question 2

2. Best prevention of pressure ulcers (Slide 15 & 16)

Answer 2

 PRIORITY should be prevention. Identify those at greatest risk!!!!
 Braden Scale for predicting pressure sore risk!

• Reduced mobility
• Sensory impairment
• Neuropathy
• Acute illness
• Level of consciousness
• Malnutrition and dehydration

Question 3

2. Pressure sore Stages

Answer 3

• Stage 1: still intact
• Stage 2: partial thickness
• Stage 3: full thickness of skin loss lead to subcutaneous
• Stage 4: full thickness damage to bone, tendon, and muscle

Question 4

3. Impetigo manifestations (Slide 9)

Answer 4

 Lesions begin as macules and develop into pustules
 Pustules rupture-form honey-colored exudate
 Usually affects face, hands, arms and legs
 High contagious-direct or indirect contact
 Low grade fever; leukocytosis

Question 5

4. Eczema client education (Slide 15)

Answer 5

 Pharmacological management
o Corticosteroids; Coal tar preparation
 Reduce exposure to allergen
 Hydration of skin: cool wet compresses
 Lotions-Eucerin, Lubriderm-three to four times a day

Question 6

5. z-track instruction (Page 398)

Answer 6

 Fill the syringe with the prescribed amount of drug and change the needle.
 Draw up an additional 0.2 mL of air in the syringe.
 Attach a needle that is at least 1½ to 2 inches long.
 Using the side of your hand, pull the tissue laterally about 1 inch (2.5 cm) until it is taut (see A). Swab the site with an alcohol pledget.
 Insert the needle at a 90° angle while continuing to hold the tissue laterally (see B).
 Steady the barrel of the syringe with the fingers and use the thumb to manipulate the plunger.
 Aspirate for a blood return.
 Instill the medication by depressing the plunger with the thumb.
 Wait 10 seconds with the needle in place and the skin still held taut.
 Withdraw the needle and immediately release the taut skin (see C).
 Apply direct pressure to the injection site with a gauze square, but do not rub it.

Question 7

6. Wood’ light nursing actions (Slide 11)

Answer 7

Fungal Infections of the skin; Dermatophytoses
 Darken room for Wood’s light exam
 Keep area clean and dry

Question 8

7. Cushing manifestations(Slide 5)

Answer 8

 Hirsutism (assess for increase or decrease of hair)
 Rosy cheeks
 Striae (stretch marks)

 Moon face
 Buffalo hump
 Elevated glucose/weight gain
 Hypertension
 Hypernatremia
 Hypokalemia

Question 9

Warts manifestations/ CE (Slide 21)

Answer 9

 Verruca (wart)
• Benign, viral warty skin lesion
• Common locations: Hands, arms, and fingers-on extremities do not hurt
• Transmitted skin to skin
• Treatment: Cauterization, solid carbon dioxide,liquid nitrogen, salicylic acid

Client educations:about changes

Question 10

8. Nevi (moles) manifestations

Answer 10

• Congenital skin blemish
• Usually benign, but may become malignant
• Assess for any changes in color, size, or texture
• Assess for bleeding or pruritus

Question 11

9. Skin cancer incidence and risks

Answer 11

 Drecrease ozone layer
 Exposure to UV radiation
 Low skin melanin
 Higher altitude
 Prolonged outdoor exposure

Question 12

10. Acne client education (Slide 10)

Answer 12

 Keep skin and hair clean
 Water-based makeup with gentle washing
 Avoid sun exposure

Question 13

11. Psoriasis client education and medical management (Slide 14)

Answer 13

 Topical steroids
 Tar preparation
 Salicylic acid
 Ultraviolet light
 Lifelong care is usually needed

Question 14

12. Skin cancer manifestations (Slide 23)

Answer 14

 Basal Cell carcinoma (most common on the face and uppper truck)
• Small translucent
• Pearly appearance
• Mighty crust over

 Squamous celll carcinoma(most common on sun exposed areas)
• Firm
• Modular lesion
• Ulceration
• Indurated margins

Question 15

13. Dehiscence nursing actions (Slide 27)

Answer 15

 Partial or total separation of wound layers
• Place client in supine position and cover with sterile dressing

Question 16

13. Evisceration nursing actions

Answer 16

 With total separation of wound the visceral organ protrudes through the wound opening
• Place sterile towel soaked in normal saline invasion, surgery

Question 17

14. Herpes zoster nursing actions (Slide 8)

Answer 17

 Avoid persons who have not had chicken pox
 Cool compresses on areas
 (You can still shed even if its not active)

Question 18

15. Scabies client education (Slide 12)

Answer 18

Nursing Management
 Pharmacological
 Treat all family members
 Wash linens and clothing in hot water using mild detergent
 Cool baths and temperature for comfort
 Avoid scratching

Question 19

16. Wound healing client education (Slide 26)

Answer 19

 Principles to maintain a healthy wound environment:
• Prevent and manage infection
• Clean the wound
• Remove nonviable tissue
• Manage exudate
• Maintain the wound in a moist environment
• Protect the wound
• Nutrition and supplement considerations: Vitamin A and C