ATI Care of Patients with Skin Problems, Questions and Answers with Explanations

1. A client has very dry skin. Which is the best intervention for the nurse to teach the client?

a.	“Be sure to use lots of moisturizer several times a day.”
b.	“Avoid wearing stockings or other constricting clothing.”
c.	“Use antimicrobial soap so scratching won’t cause infection.”
d.	“After you bathe, put lotion on before your skin is totally dry.”

ANS: D

The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Constricting clothing is not related to dry skin, and antimicrobial soaps are actually more drying than other kinds of soap.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene)

MSC: Integrated Process: Teaching/Learning

2. Which intervention best assists a client with pruritus?

a.	“Keep your fingernails cut short and keep them clean.”
b.	“Drinking extra fluids decreases stimulation of itch receptors.”
c.	“Wear soft, breathable clothing made from material like cotton.”
d.	“Avoid immersing the areas in water and dry thoroughly after bathing.”

ANS: A

The focus of nursing care is to improve client comfort and to prevent injury to the skin from scratching. Keeping nails short will help prevent injury, and keeping them clean will help prevent infection should injury to the skin occur. Extra fluids do not change the sensations felt at the itch receptors. Cotton clothing does nothing to help extreme itching, and skin should be lubricated after bathing before drying off.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

3. A client has urticaria and has been prescribed diphenhydramine (Benadryl). Which information is most important for the nurse to teach the client?

a.	“Wear sunscreen when you are outside.”
b.	“Avoid drinking alcoholic beverages.”
c.	“Do not take aspirin-containing drugs.”
d.	“Take this medicine on a full stomach.”

ANS: B

Benadryl is an antihistamine that will decrease itching. For most people, diphenhydramine causes drowsiness. This side effect is intensified when alcohol is also consumed, placing the client at increased risk for injury and falls. Aspirin will not interact with this medication. Sun exposure and timing related to meals should not affect administration of the drug.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

4. When changing the dressing on a partial-thickness wound, a nurse observes small, pale pink bumps within the wound bed. Which action by the nurse is best?

a.	Remove the bumps with a sterile scalpel.
b.	Document and continue the current treatment.
c.	Clean the wound vigorously to remove the bumps.
d.	Culture the wound and place the client in isolation.

ANS: B

The small, pale pink bumps consist of granulation tissue characteristic of new capillary bed growth (capillary buds)—an indication of proper wound healing. The nurse should continue current treatment and assessments. Attempting to remove the bumps in any way can interfere with healing. No reason for culturing the wound or placing the client in isolation is known.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

5. Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound?

a.	Ensure that the client is systemically oxygenated.
b.	Restrict the client’s movement with bedrest.
c.	Cover the wound with an airtight dressing.
d.	Apply hydrocortisone cream as ordered.

ANS: A

Wounds heal best in tissue that is well oxygenated and hydrated, and is kept free of microorganisms. Ensuring that the client is well oxygenated will help bring oxygen and cellular nutrition to the wound. Covering the wound will deprive the new tissue of nutrition and will not enhance healing. Although the client may need to limit the motion of an affected extremity to avoid further trauma, placing a client on bedrest will lead to complications of immobility. Hydrocortisone cream may decrease itching but will not enhance healing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

No comments found.

This item has not received any review yet.

No Questions / Answers added yet.