UNIT 5: Management of Patients with Dermatologic Conditions

Question 1

1. A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
   A. Acyclovir
   B. Benzoyl peroxide and erythromycin
   C. Diphenhydramine
   D. Triamcinolone

Answer 1

ANS: B
Rationale: Benzoyl peroxide and erythromycin gel is among the topical treatments available for acne. Acyclovir is used in the treatment of herpes zoster as an oral antiviral agent. Diphenhydramine is an oral antihistamine used in the treatment of pruritus.
Intralesional injections of triamcinolone have been utilized in the treatment of psoriasis.

Question 2

2. A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?
   A. Lifelong management is likely needed.
   B. Avoid public places until symptoms subside.
   C. Wash skin frequently to prevent infection.
   D. Liberally apply corticosteroids as needed.

Answer 2

ANS: A
Rationale: Psoriasis usually requires lifelong management. Psoriasis is not contagious. Many clients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessive frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

Question 3

3. A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?
   A. Prednisone
   B. Azathioprine
   C. Triamcinolone
   D. Acyclovir

Answer 3

ANS: D
Rationale: Acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. There is evidence that infection is arrested if oral antiviral agents are given within the first 24 hours. Prednisone is an anti-inflammatory agent used in a variety of skin disorders, but not in the treatment of herpes. Azathioprine is an immunosuppressive agent used in the treatment of pemphigus. Triamcinolone is utilized in the treatment of psoriasis

Question 4

4. A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
   A. Chemotherapy
   B. Radiation therapy
   C. Surgical excision
   D. Biopsy of sample tissue

Answer 4

ANS: C
Rationale: The primary goal of surgical management of squamous cell carcinoma is to remove the tumor entirely. Radiation therapy is reserved for older clients, because x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. Obtaining a biopsy would not be a goal of treatment; it may be an assessment. Chemotherapy and radiation therapy are generally reserved for clients who are not surgical candidates.

Question 5

5. A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Low Self Esteem related to use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this diagnosis?
   A. Referring the client to a speech therapist
   B. Gradually adding soft foods to diet
   C. Administering analgesics as prescribed
   D. Teaching the client how to use and care for the prosthesis

Answer 5

ANS: D

Rationale: The process of facial reconstruction is often slow and tedious. Because a person’s facial appearance affects self-esteem so greatly, this type of reconstruction is often a very emotional experience for the client. Reinforcement of the client’s successful coping strategies improves self-esteem. If prosthetic devices are used, the client is taught how to use and care for them to gain a sense of greater independence. This is an intervention that relates to Disturbed Body Image in these clients. None of the other listed interventions relate directly to the diagnosis of Disturbed Body Image.

Question 6

6. While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client’s ear. The nurse knows that this lesion is consistent with what type of skin cancer?
   A. Basal cell carcinoma
   B. Squamous cell carcinoma
   C. Dermatofibroma
   D. Malignant melanoma

Answer 6

ANS: D
Rationale: A malignant melanoma presents itself as a superficial spreading melanoma which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. The lesion tends to be circular, with irregular outer portions. BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding. A dermatofibroma presents as a firm, dome-shaped papule or nodule that may be skin colored or pinkish brown.

Question 7

7. A nurse is providing care for a client who has developed Kaposi sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?
   A. Connective tissue cells in diffuse locations
   B. Smooth muscle cells of the gastrointestinal and respiratory tract
   C. Neural tissue of the brain and spinal cord
   D. Endothelial cells lining small blood vessels

Answer 7

ANS: D
Rationale: Kaposi sarcoma (KS) is a malignancy of endothelial cells that line the small blood vessels. It does not originate in connective tissue, smooth muscle cells of the GI and respiratory tract, or in neural tissue.

Question 8

8. A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected?
   A. The largest area of the body without hair is selected.
   B. Any area that is not normally visible can be used.
   C. An area matching the color and texture of the skin at the surgical site is selected.
   D. An area matching the sensory capability of the skin at the surgical site is selected.

Answer 8

ANS: C

Rationale: The site where the intact skin is harvested is called the donor site. Selection of
the donor site is made to match the color and texture of skin at the surgical site and to leave as little scarring as possible.

Question 9

9. A client has just been told that he has deep malignant melanoma. The nurse caring for this client should anticipate that the client will undergo what treatment?
   A. Chemotherapy
   B. Immunotherapy
   C. Wide excision
   D. Radiation therapy

Answer 9

ANS: C
Rationale: Wide excision is the primary treatment for malignant melanoma, which removes the entire lesion and determines the level and staging. Chemotherapy may be used after the melanoma is excised. Immunotherapy is experimental and radiation therapy is palliative

Question 10

10. A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants’ risks of basal cell carcinoma (BCC)?
    A. Teaching participants to improve their overall health through nutrition
    B. Encouraging participants to identify their family history of cancer
    C. Teaching participants to limit their sun exposure
    D. Teaching participants to control exposure to environmental and occupational radiation

Answer 10

ANS: C

Rationale: Sun exposure is the best known and most common cause of BCC. BCC is not commonly linked to general health debilitation, family history, or radiation exposure.

Question 11

11. A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
    A. Assess the drainage in the dressing.
    B. Slowly remove the soiled dressing.
    C. Perform hand hygiene.
    D. Don nonlatex gloves

Answer 11

NS: C

Rationale: The nurse and health care provider must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

Question 12

12. A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?
    A. Grouped vesicles occurring on lips and oral mucous membranes
    B. Grouped vesicles occurring on the genitalia
    C. Rough, fresh, or gray skin protrusions
    D. Grouped vesicles in linear patches along a dermatome

Answer 12

ANS: D

Rationale: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

Question 13

13. A nurse is preparing to assist a surgeon in a skin grafting procedure. What can a skin graft can be used for?
    A. Denuded skin after burns.
    B. Slow healing wounds.
    C. Uncomplicated wound closure.
    D. Infected wounds.

Answer 13

ANS: A

Rationale: Skin grafts are commonly used to repair surgical defects such as those that result from excision of skin tumors, to cover areas denuded of skin (e.g., burns), and to cover wounds in which insufficient skin is available to permit wound closure. They are also used when primary closure of the wound increases the risk of complications or when primary wound closure would interfere with function. It is not used for uncomplicated wound closure. Skin grafts are not used for infected wounds.

Question 14

14. A client presents at the free clinic with a black, wart-like lesion on his face, stating, “I’ve done some research, and I’m pretty sure I have malignant melanoma.” Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?
    A. The client requires no treatment unless he finds the lesion to be cosmetically unacceptable.
    B. The client’s lesion will be closely observed for 6 months before a plan of treatment is chosen.
    C. The client has one of the few dermatologic malignancies that respond to chemotherapy.
    D. The client will likely require wide excision.

Answer 14

ANS: A

Rationale: Seborrheic keratoses are benign, wart-like lesions of various sizes and colors, ranging from light tan to black. There is no harm in allowing these growths to remain because there is no medical significance to their presence.

Question 15

15. A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment?
    A. Assessment of the client’s stool for evidence of intestinal sloughing
    B. Assessment of the client’s apical heart rate for dysrhythmias
    C. Assessment of the client’s joints for pain and decreased range of motion
    D. Assessment for cognitive changes resulting from neurologic lesions

Answer 15

ANS: C
Rationale: Asymmetric rheumatoid factor–negative arthritis of multiple joints occurs in up to 42% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

Question 16

16. A client is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the client, the nurse would be alert to what precipitating factor?
    A. Recent heavy ultraviolet exposure
    B. Substandard hygienic conditions
    C. Recent administration of new medications
    D. Recent varicella infection

Answer 16

ANS: C
Rationale: In adults, TEN is usually triggered by a reaction to medications. Antibiotics, anticonvulsant agents, butazones, and sulfonamides are the most frequent medications implicated. TEN is unrelated to UV exposure, hygiene, or varicella infection.

Question 17

17. A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client’s subsequent care?
    A. Teaching the client to safely and effectively administer immunosuppressants
    B. Helping the client identify and avoid the offending agent
    C. Teaching the client how to maintain meticulous skin hygiene
    D. Helping the client perform wound care in the home environment

Answer 17

ANS: B
Rationale: A focus of care for clients with irritant contact dermatitis is identifying and avoiding the offending agent. Immunosuppressants are not used to treat eczema and wound care is not normally required, except in cases of open lesions. Poor hygiene has no correlation with contact dermatitis

Question 18

18. A nurse is caring for a client whose chemical injury has necessitated a skin graft to the
    client’s left hand. Which statement is true regarding skin graft use?
    A. This use is not a type of reconstruction.
    B. Skin grafts form their own blood supply.
    C. They are only transplanted from another doner.
    D. Skin is transferred from a distant site to the graft site.

Answer 18

ANS: D

Rationale: Skin grafting is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site. Skin grafting can be used to repair almost any type of wound and is the most common form of reconstructive surgery.

Question 19

19. A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
    A. The child’s scalp should be monitored for 48 to 72 hours before starting treatment.
    B. Nits may have to be manually removed from the child’s hair shafts.
    C. The disease is self-limiting and symptoms will abate within 1 week.
    D. Efforts should be made to improve the child’s level of hygiene

Answer 19

ANS: B
Rationale: Treatment for head lice should begin promptly and may require manual removal of nits following medicating shampoo. Head lice are not related to a lack of hygiene. Treatment is necessary because the condition will not likely resolve spontaneously within 1 week.

Question 20

20. A client has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the client about topical corticosteroid use on these lesions?
    A. Cataract development is possible.
    B. The ointment is likely to cause weeping.
    C. Corticosteroid use is contraindicated on these lesions.
    D. The client may develop glaucoma.

Answer 20

ANS: A

Rationale: Clients using topical corticosteroid preparations repeatedly on the face and around the eyes should be aware that cataract development is possible. Weeping and glaucoma are less likely. There is no consequent risk of glaucoma.

Question 21

21. A nurse is caring for a client who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. The nurse knows that systemic treatment will most likely include which element?
    A. Corticosteroid therapy
    B. Skin biopsy
    C. Topical corticosteroids
    D. Penicillin therapy

Answer 21

ANS: A
Rationale: Treatment for bullous pemphigoid includes system corticosteroid therapy. This would not include skin biopsy as this is for diagnostics. Topical corticosteroids don’t treat systemically. The goal of therapy is to respond to inflammation, not to treat
infection.

Question 22

22. A client’s blistering disorder has resulted in the formation of multiple lesions in the client’s mouth. What intervention should be included in the client’s plan of care?
    A. Provide chlorhexidine solution for rinsing the client’s mouth.
    B. Avoid providing regular mouth care until the client’s lesions heal.
    C. Liaise with the primary provider to arrange for parenteral nutrition.
    D. Encourage the client to gargle with a hypertonic solution after each meal.

Answer 22

ANS: A

Rationale: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.

Question 23

23. When caring for a client with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what condition(s)? Select all that apply.
    A. Possible malignancy
    B. Epidermal necrosis
    C. Neurologic involvement
    D. Increased metabolic needs
    E. Possible gastrointestinal mucosal sloughing

Answer 23

ANS: B, D, E
Rationale: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

Question 24

24. A nurse is assessing a teenage client with acne vulgaris. The client’s mother states, “I keep telling him that this is what happens when you eat as many french fries as he does.” What aspect of the pathophysiology of acne should inform the nurse’s response?
    A. A sudden change in client’s diet may exacerbate, rather than alleviate, the client’s symptoms.
    B. French fries are one of the foods that are known to directly cause acne.
    C. Elimination of fried foods from the client’s diet will likely lead to resolution within several months.
    D. Diet is thought to play a minimal role in the development of acne.

Answer 24

ANS: D

Rationale: Diet is not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms. However, there does appear to be a correlation between foods high in refined sugars and acne; therefore, these foods should be avoided

Question 25

25. A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client?
    A. “Wash your face with water and gentle soap each morning and evening.”
    B. “Before bedtime, clean your face with rubbing alcohol on a cotton pad.”
    C. “Gently burst new pimples before they form a visible ‘head’.”
    D. “Set aside some time each day to squeeze blackheads and remove the plug.”

Answer 25

ANS: A
Rationale: The nurse should inform the client to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. Cleansing with rubbing alcohol is not recommended and all forms of manipulation should be avoided

Question 26

26. A nurse is caring for a client whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
    A. Teach the client about early signs of secondary blistering diseases.
    B. Teach the client about self-care after treatment.
    C. Assess the client’s risk for recurrent malignancy.
    D. Assess the client for adverse effects of radiotherapy.

Answer 26

ANS: B

Rationale: Because many skin cancers are removed by excision, clients are usually treated in outpatient surgical units. The role of the nurse is to teach the client about prevention of skin cancer and about self-care after treatment. Assessing the client’s risk for recurrent malignancy is primarily the role of the health care provider. Blistering diseases do not result from cancer or subsequent excision. Excision is not accompanied by radiotherapy.

Question 27

27. A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
    A. Maintain the client on bed rest for the first 24 hours postoperative.
    B. Apply distraction techniques to relieve pain.
    C. Provide soft or liquid diet that is high in protein to assist with healing.
    D. Anticipate the need for, and administer, appropriate analgesic medications.

Answer 27

ANS: D

Rationale: Nursing interventions after surgery for a malignant melanoma center on promoting comfort, because wide excision surgery may be necessary. Anticipating the need for and administering appropriate analgesic medications are important. Distraction techniques may be appropriate for some clients, but these are not a substitute for analgesia. Bed rest and a modified diet are not necessary.

Question 28

28. A nurse educator is teaching a group of nurses about Kaposi sarcoma. What would the educator identify as characteristics of endemic Kaposi sarcoma? Select all that apply.
    A. Affects people predominantly in the eastern half of Africa
    B. Affects men more than women
    C. Does not affect children
    D. Cannot infiltrate
    E. Can progress to lymphadenopathic forms

Answer 28

ANS: A, B, E
Rationale: Endemic (African) Kaposi sarcoma affects people predominantly in the eastern half of Africa, near the equator. Men are affected more often than women, and children can be affected as well. The disease may resemble classic KS or it may infiltrate and progress to lymphadenopathic forms.

Question 29

29. A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi sarcoma. The nurse caring for this client recognizes that this is what type of Kaposi sarcoma?
    A. Classic
    B. AIDS related
    C. Iatrogenic
    D. Endemic

Answer 29

ANS: C
Rationale: Iatrogenic/organ transplant–associated Kaposi sarcoma occurs in transplant recipients and people with AIDS. This form of KS is characterized by local skin lesions and disseminated visceral and mucocutaneous diseases. Classic Kaposi sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Endemic KS affects people predominantly in the eastern half of Africa. AIDS-related KS is seen in people with AIDS.

Question 30

30. A 65-year-old man presents at the clinic reporting nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?
    A. Stasis ulcers
    B. Bullous pemphigoid
    C. Psoriasis
    D. Classic Kaposi sarcoma

Answer 30

ANS: D
Rationale: Classic Kaposi sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Most clients have nodules or plaques on the lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal. Stasis ulcers do not create nodules. Bullous pemphigoid is characterized by blistering. Psoriasis characteristically presents with silvery plaques

Question 31

31. A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the client is likely seeking treatment for which of the following?
    A. Wrinkles near the lips and eyes
    B. Removal of acne scars
    C. Vascular lesions on the cheeks
    D. Real or perceived misshaping of the eyes

Answer 31

ANS: A
Rationale: Chemical face peeling is especially useful for wrinkles at the upper and lower lip, forehead, and periorbital areas. Chemical face peeling does not remove acne scars, remove vascular lesions, or reshape the eyes.

Question 32

32. A client comes to the dermatology clinic requesting the removal of epidermal nevi on the client’s right cheek. The nurse knows that the procedure especially useful in treating such lesions is what?
    A. Skin graft
    B. Laser treatment
    C. Chemical face peeling
    D. Free flap

Answer 32

ANS: B
Rationale: Lasers are useful in treating cutaneous vascular lesions such as epidermal nevi. Skin grafts, chemical face peels, and free flaps would not be used to remove this lesion.

Question 33

33. A 30-year-old client has just returned from the operating room after having a “flap” done following a motorcycle accident. The client’s spouse asks the nurse about the major complications following this type of surgery. What would be the nurse’s best response?
    A. “The major complication is when the client develops chronic pain.”
    B. “The major complication is when the client loses sensation in the flap.”
    C. “The major complication is when the pedicle tears loose and the flap dies.”
    D. “The major complication is when the blood supply fails and the tissue in the flap dies.”

Answer 33

ANS: D

Rationale: The major complication of a flap is necrosis of the pedicle or base as a result of failure of the blood supply. This is more likely than tearing of the pedicle and chronic pain and is more serious than loss of sensation.

Question 34

34. A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
    A. Educating participants about the relationship between general health and the risk of skin cancer
    B. Educating participants about treatment options for skin cancer
    C. Educating participants about the early signs and symptoms of skin cancer
    D. Educating participants about the health risks associated with smoking and assisting with smoking cessation

Answer 34

ANS: C

Rationale: The best hope of decreasing the incidence of skin cancer lies in educating clients about the early signs. There is a relationship between general health and skin cancer, but teaching individuals to identify the early signs and symptoms is more likely to benefit overall outcomes related to skin cancer. Teaching about treatment options is not likely to have a major effect on outcomes of the disease. Smoking is not among the major risk factors for skin cancer.

Question 35

35. An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident’s plan of care?
    A. Avoid the application of skin emollients
    B. Apply antibiotic ointment, as prescribed, following baths
    C. Avoid using hot water during the client’s baths
    D. Administer acetaminophen four times daily as prescribed

Answer 35

ANS: C
Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

Question 36

36. A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this client’s care, the nurse should include what nursing diagnosis?
    A. Risk for deficient fluid volume related to excess sebum synthesis
    B. Ineffective thermoregulation related to occlusion of sebaceous glands
    C. Disturbed body image related to excess sebum production
    D. Ineffective tissue perfusion related to occlusion of sebaceous glands

Answer 36

ANS: C
Rationale: Seborrhea causes highly visible manifestations that are likely to have a negative effect on the client’s body image. Seborrhea does not normally affect fluid balance, thermoregulation, or tissue perfusion.

Question 37

37. A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family’s care?
    A. Ensuring that the family knows that impetigo is not contagious
    B. Teaching about the safe and effective use of topical corticosteroids
    C. Teaching about the importance of maintaining high standards of hygiene
    D. Ensuring that the family knows how to safely burst the child’s vesicles

Answer 37

ANS: C
Rationale: Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective.

Question 38

38. The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:
    A. perform range-of-motion exercises.
    B. avoid placing body weight on the healing site.
    C. elevate body parts that are susceptible to edema.
    D. demonstrate the technique for massaging the wound site

Answer 38

ANS: B

Rationale: The major goals of pressure injury treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the client teaching.

Question 39

39. An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?
    A. I
    B. II
    C. III
    D. IV

Answer 39

ANS: D
Rationale: Stage III and IV pressure injuries are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure injuries must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.