What is the nurse's primary focus in the management of urticaria? Show 2 Removal of the triggering substance and the relief of its manifestations are important nursing interventions in the management of urticaria. Increasing patient comfort and preventing skin injury with loss of tissue integrity are the interventions used in the management of pruritus. Checking for the presence of necrotic tissue and amount of exudates is an intervention used to manage pressure injuries What category of medication may affect the wound contraction of wound healing? 3 Cytotoxic drugs impair cellular regulation and collagen synthesis and decrease wound contraction. Wound contraction occurs in the second intention phase of wound healing. Antibiotic use is avoided in the absence of infection to reduce the development of resistant bacterial strains. Concomitant use of alcohol and antihistamine should be avoided because they may increase the sedating affect. Non-steroidal anti-inflammatory drugs should not be used in wound healing because they may alter the inflammatory response. Which category of medications can aggravate psoriasis? Beta-blocking agents can make psoriasis worse. Antibiotics, barbiturates, and sulfonamides can cause toxic epidermal necrolysis and do not make psoriasis worse. What
is the dosage frequency of adalimumab? 2 Adalimumab is administered through the subcutaneous route with the loading dose followed by a maintaining dose every other week that is started 1 week after the loading dose. IV infusions of infliximab are administered at 0, 2, and 6 weeks and then every 8 weeks. Etanercept is administered through the subcutaneous route twice weekly for 3 months, followed by once-a-week injections. Alefacept is administered through the intramuscular route once a week for 12 weeks followed by a 12-week drug-free interval. What process of wound healing involves the production of
keratin? 1 Resurfacing involves regrowth across open surfaces, which is one cell layer thick. As healing continues, the cell layer stratifies and produces keratin. Granulation replaces damaged tissue with scar tissue and aids in wound healing. Contraction involves pulling wound edges inward along the path of least resistance. Re-epithelialization involves the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis. Which surgical technique helps to remove full-thickness skin in the area of a lesion? 2 Wide excision is used to remove full-thickness skin in the area of a lesion. Cryosurgery is used to treat isolated lesions, causing cell death and destruction. Mohs' surgery is a specialized form of excision that is usually preferred for squamous cell carcinomas. Excisional biopsy refers to total surgical removal of the small lesions for pathological examination. Which skin infection is associated with a typical "satellite lesion"? 3 " Satellite lesions" are erythematous macular eruptions that occur with isolated pustules or papules at the border. This typical feature is associated with candidiasis. Shingles is a skin infection caused by the varicella-zoster virus and does not have satellite lesions. The infection follows the path of the affected nerve. A furuncle is a skin infection caused by bacteria, involving deeper portions of the follicle. These are characterized by erythematous lesions filled with pus. Dermatophytosis is a fungal infection characterized by serpiginous patches. Which are common complications of pressure injuries? Select all that apply. 1,5 Pressure injuries may lead to sepsis because there is a possibility of infection through the wound. Pressure injuries may also affect kidney function, leading to kidney failure. Diabetes can put a patient at higher risk for the formation of injuries, but it is not a complication of pressure injuries. Uremia and cirrhosis are not complications associated with pressure injuries. Which medication is most effective for the treatment of multiple actinic keratosis? 4 Topical therapy with 5-fluorouracil is used in the treatment of multiple actinic keratosis. Systemic therapy of cisplatin and cetuximab are used to treat advanced or metastatic squamous cell carcinoma. Topical therapy of vismodegib is used to treat advanced or metastatic basal cell skin cancer. Which condition may worsen itching in patients with pre-existing pruritus? 2 Perspiration can make pre-existing pruritus (itching) worse because the sweat may further increase skin irritation. Dehydration, overexertion, and alcohol consumption will not worsen pre-existing pruritus. Which drug-induced skin reaction is characterized by vesicles, erosions, and crusts? 4 Stevens-Johnson syndrome is a drug-induced skin reaction, typically characterized by vesicles, erosions, and crusts. In psoriasis, the lesions are scaled with underlying dermal inflammation. Basal cell carcinoma appears as papule with central crater and rolled waxy borders. Toxic epidermal necrolysis is associated with diffused erythema and large blisters. A
patient with contact dermatitis reports redness in the earlobes. What could be the reason for this? 2 Nickel allergy is most commonly seen in patients who are exposed to nickel. If the earlobes are red, the nurse should ask about earrings that might cause inflammation of the ears. A latex allergy will manifest when a person comes into contact with latex. Cosmetic allergies involve the head and neck. Airborne contact allergy is seen in patients who come into contact with paint or ragweed. Which condition will occur from stimulation of the itch-specific nerve fibers? 1 Pruritus occurs when the itch-specific nerve fibers are stimulated. Cellulitis occurs due to inflammation or infection of the skin and subcutaneous tissue. Urticaria is caused by exposure to allergens, which releases histamine into the skin. Pressure injuries occur when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an external period. Which skin infection may spread to patients from health care personnel? 4 Herpetic whitlow is a form of herpes simplex virus that occurs on the fingertips of health care personnel. This happens when they come in contact with viral secretions. Herpetic whitlow can easily spread to patients. Folliculitis is a bacterial infection and may spread through direct contact with an infected person. Candidiasis is a fungal infection that spreads through direct contact with an infected person. Herpes zoster is seen in patients who have a history of chicken pox. Which part of the body is least likely to be affected by psoriasis? 4 Facial skin is rarely affected by psoriasis. Scalp, trunk, and knees are the common sites that are affected by psoriasis. Which systemic drug is most commonly used to treat
psoriasis? 1 Systemic therapy is used in the treatment of psoriasis, when the patient does not respond to topical therapies. Bexarotene is a vitamin A derivative that is most commonly used to treat psoriasis. Azathioprine, cyclosporine, and methotrexate are less commonly used systemic drugs for psoriasis. Which medication
acts as a strong irritant and causes chemical burns in patients with psoriasis? 1 Which is a risk
factor for candidial infection? 4 Diabetes mellitus is a risk factor for candidial infection. In pregnancy, drugs should be used with caution; therefore, it is not associated with candidial infections. Weight loss can happen with anthrax. Hypertension is not a risk factor for candidial infections. Pressure mapping is used
to measure pressure distribution. What does the blue color indicate in a pressure map? 4 The process of pressure mapping involves the use of a computerized tool that measures pressure distribution for a person sitting in a chair or lying on a mattress. The map is displayed as colored areas on the computer screen based on temperature differences. Shades of blue indicate cooler areas under lower pressure. Greater heat production is indicated by shades of red. Severity and the most common pressure injury areas are not indicated on a pressure map. What is the duration of the first phase of wound healing? 1 The first phase of wound healing is the inflammatory phase; this phase begins at the time of injury or cell death and lasts for 3 to 5 days. The duration of wound healing that occurs in partial wound thickness is 5 to 7 days. The duration of wound healing that occurs in the proliferative phase is 2 to 4 weeks. Wound healing lasts for 3 weeks or longer in the maturation phase. Which process promotes the healing of partial-thickness
wounds? 3 Partial-thickness wounds are more superficial. In a partial-thickness wound, only the epidermis and upper layers of the dermis are damaged. Such wounds heal by re-epithelialization. Granulation is a major process for deep wounds. Maturation is not involved in the healing of partial-thickness wounds. In wound contraction, the size of the wound decreases and the wound finally closes. What is the underlying cause of urticaria? 1 Urticaria is a rash of white or edematous papules or plaques caused by exposure to allergens. An aseptic surgical incision may cause skin trauma by affecting the tissue integrity. The compression of underlying soft tissue between a bony prominence over an extended period may cause deep pressure injuries by causing a loss of tissue integrity. Pruritus causes distress due to stimulation of the itch-specific receptors. What method does the nurse use to measure the length of a patient's wound? 1 To standardize wound size for documentation and communication purposes, the wound is assessed as a clock face, with the 12 o'clock position in the direction of the patient's head and the 6 o'clock position in the direction of the patient's feet. Length can be measured from the 12 o'clock position to the 6 o'clock position. Width can be measured from 9 o'clock position and the 3 o'clock position. The 11 to 5 o'clock position and 7 to 2 o'clock position are not used for wound measurement. Which clinical manifestation is observed during the inflammatory phase of wound healing? 2 Erythema is a clinical manifestation that occurs during the inflammatory phase of wound healing. It is characterized by redness or swelling of the skin that exists from skin trauma due to an aseptic surgical incision or a pressure injury. Itching is a clinical feature that occurs in pruritus. Injuries on body surfaces such as the sacrum, hips, and ankles are a characteristic feature in pressure injuries. A rash of white edematous papules or plaques occurs in urticaria. Which risk categories are measured
by the Braden Scale assessment tool? Select all that apply. 1,2,3,4 The Braden Scale is the most commonly used skin risk assessment tool. This validated tool helps to assess various risk categories for pressure injury formation, including mobility, mental status, incontinence, and nutritional status. Pressure distribution can be measured by the pressure mapping process. Which body area is most commonly affected by psoriasis? 3 The elbow is commonly affected by psoriasis. Neck, chest, and facial skin are rarely affected with psoriasis. The nurse is teaching a patient about decreasing the risk for melanomas and other skin cancers.
Which primary prevention technique is most important for the nurse to include? 3 Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). Avoiding tanning beds is significant but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important. Deep tissue wounds, such as chronic pressure injuries, take longer to heal because they heal by which
intention? 4 Second intention healing is seen in wounds that can be described as cavity-like defects. This type of healing, in deeper tissue injuries or wounds with tissue loss, requires gradual filling in of the dead space with connective tissue in. This process occurs over an extended period. First intention healing occurs in wounds without tissue loss. These wounds can be easily closed and dead space eliminated. Third intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is debrided and inflammation subsides. Mixed intention healing does not exist. A full-thickness pressure injury is covered by a layer of black nonviable, denatured collagen. What term is used to describe this
condition? 4 A full-thickness pressure injury covered with a layer of black, gray, or brown nonviable, denatured collagen is called wound eschar. Cellulitis is the inflammation of skin cells. Urticaria is the formation of white or red edematous papules or plaques of different sizes (hives). Separation of skin layers at the wound margin from the underlying granulation tissue is known as undermining. What is the dosage frequency of adalimumab? 2 Adalimumab is administered through the subcutaneous route with the loading dose followed by a maintaining dose every other week that is started 1 week after the loading dose. IV infusions of infliximab are administered at 0, 2, and 6 weeks and then every 8 weeks. Etanercept is administered through the subcutaneous route twice weekly for 3 months, followed by once-a-week injections. Alefacept is administered through the intramuscular route once a week for 12 weeks followed by a 12-week drug-free interval. Which
inflammatory condition leads to dehydration and hypothermia? 3 Exfoliative psoriasis causes dehydration and hypothermia. Psoriasis vulgaris leads to thickened skin lesions on both sides of the body. Psoriatic arthritis leads to severe complications associated with joints. Palmoplantar pustulosis may cause social and physical problems. Which is a common causative drug of toxic epidermal necrolysis (TEN)? 1 Pyrazolones are one of the most common drugs that can cause TEN. Tetracyclines and opioid analgesics may not cause TEN. Beta-blocking agents can aggravate psoriasis, but not TEN. Which skin cancer mostly
occurs at the site of moles and birthmarks? 1 Melanoma may occur anywhere in the body and is especially evident at the site of birthmarks and moles. Actinic keratosis may be distributed on the cheeks, temples, forehead, ears, neck, backs of hands, and forearms. Basal cell carcinoma occurs on sun-exposed areas, especially head, neck, and central portion of the face. Squamous cell carcinoma occurs on sun-exposed areas. A patient has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the patient? 3 Performing a monthly total skin self-examination with another person is the best secondary preventive measure. If the patient is taught to use the ABCDE ( asymmetry, border, color, diameter, and evolving) method of lesion assessment, the patient will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. It is difficult for a person to assess all of the skin surfaces of his or her body by him- or herself, even with the use of mirrors. It is better to involve a partner with the assessment. A hospitalized patient has severe nutritional deficits and ongoing protein loss, which puts the patient at high risk for the development of pressure injuries. How much protein intake, in g/kg/day, is required for this patient to reduce the risk? Record your answer using a whole number. ___g/kg/day 2 Nutritional status plays an important role in the healing process. Up to 2 g/kg/day of protein may be needed when nutritional deficits are severe or protein loss is ongoing. An intake of 1.25 to 1.5 g/kg/day is the normal amount of protein people should consume. An amount of 3 g/kg/day is too much protein intake and not recommended. The nursing instructor reviews instructions with the nursing student on caring for an older adult patient with a pressure injury. What action by the nursing student
indicates a need for further instruction about proper skin care for this patient? 3 Massaging bony prominences should be avoided in older adult patients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The patient should be repositioned at least every 1 to 2 hours to prevent injury extension and the generation of additional pressure injuries. Using a moisturizing lotion is appropriate. Which type of cancer is resistant to radiation therapy? 1 Melanoma is relatively resistant to radiation therapy. It is manifested as pigmented papule or plaque and may not involve any skin invasion. Actinic keratoses, basal cell carcinoma, and squamous cell carcinoma are not resistant to radiation therapy and can be effectively treated with radiation. What condition can greatly increase the risk of accelerated tissue destruction in a patient with pressure injuries? 3 Skin and wound healing depend on a positive nitrogen balance and adequate serum protein levels. A negative nitrogen balance slows down the healing mechanism and increases the risk for accelerated tissue destruction. Mechanical obstacles and a decrease in skin moisture may hamper the wound healing process, but do not cause accelerated tissue destruction. Exposure to ultraviolet light causes sunburn. While assessing a patient, the nurse finds irregularly shaped, pigmented papule and variegated colors, with red tones on the upper back. Which condition does the nurse suspect in this patient? 1 Melanoma may be manifested by irregular shaped, pigmented papule and variegated colors with red tones distributed on the upper back. Actinic keratosis includes small papules with dry, rough, adherent yellow or brown scales. Basal cell carcinoma includes pearly papules with a central crater and rolled waxy borders. Squamous cell carcinoma is characterized by the firm nodular lesion topped with a crust and a central area of ulceration. What does the nurse tell an older patient and family about preventing skin cancer? 1 Any changes in existing lesions should be reported to the health care provider, such as changes in color, size, shape, sensation, or character of the lesion. The patient should avoid exposure to the sun between 11 AM and 3 PM when UV light is at its strongest. The patient should wear a hat, sunglasses, and opaque clothing when going out in the sun. The patient should also keep a body map of all spots, scars, or lesions. Which statement by a patient with psoriasis indicates to the nurse that additional teaching about the patient's condition is required? 3 Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these patients; this statement indicates that the patient requires further teaching. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis. Which features are associated with basal cell carcinoma? 2 Basal cell carcinoma is characterized by pearly papules with a central crater and rolled waxy borders on the sun-exposed areas. Actinic keratosis includes small papules with dry, rough, adherent yellow or brown scales. Squamous cell carcinoma involves firm nodular lesions topped with a crust with a central area of ulceration. Melanoma may be manifested by the appearance of irregular shaped, pigmented papule, and variegated colors with red tones. A patient who is on drug therapy for
epilepsy reports diffused redness and large blisters on buccal mucosa. What could be the possible reason behind this condition? 1 Barbiturates are anti-epileptic drugs used to treat epilepsy. Toxic epidermal necrolysis (TEN) is most commonly caused by barbiturates. Diffused redness and large blisters on buccal mucosa are the clinical signs of TEN. Though pyrazolones and sulfonamides also cause TEN, but they are not used in treating epilepsy. Benzodiazepines are used to treat epilepsy, but these medications may not cause TEN. During the follow-up visit, a patient reports the spontaneous disappearance and reappearance of small maculae with dry, yellow adherent scales on the skin. Which type of skin cancer does the nurse suspect in this
patient? 2 Actinic keratosis is characterized by small papule with dry, rough, adherent yellow or brown scales having an erythematous base. It may disappear spontaneously and reappear after the treatment. Melanoma involves the rapid invasion with metastasis of the pigmented papule and variegated colors with red tones. Basal cell carcinoma includes pearly papules with a central crater and rolled waxy borders on the sun exposed areas. Squamous cell carcinoma involves firm nodular lesions topped with a crust with a central area of ulceration. Which of the following is the most common type of psoriasis? 2 Psoriasis vulgaris is the most common type of psoriasis, with thick, reddened papules or plaques covered by silvery white scales. Exfoliative psoriasis (erythrodermic psoriasis) is an explosively eruptive and inflammatory form. Palmoplantar pustulosis (PPP) is a type of psoriasis that forms pustules on the palms of the hands and soles of the feet. Psoriasis is not axillary in nature. A patient with psoriasis is prescribed topical corticosteroids. Which nursing instruction regarding
medication usage would be beneficial to this patient? 4 A local tissue reaction may be caused due to corticosteroid therapy, so the patient should check regularly for local tissue reactions such as redness. Corticosteroids are not teratogenic, so maintaining strict contraceptive measures is not required. A moist dressing should be used over the site for each application of the drug. This helps to increase the absorption of the corticosteroids, but this needs to be prescribed by the health care provider, depending on the potency of the topical corticosteroid. Corticosteroids do not cause any harmful effect if the drug comes into contact with the skin Arrange
the events of pathophysiology of psoriasis chronologically. 1.Overstimulation of Langerhans' cells Which
medication has the potential to cause teratogenic effects in a patient with psoriasis? 3 Tazarotene is a topical agent used to treat psoriasis, but this medication is teratogenic and can cause birth defects. Anthralin, calcitriol, and calcipotriene are topical agents that may cause local tissue reaction. A patient is diagnosed
with squamous cell carcinoma. Which surgical technique would be effective in treating this condition? 3 Mohs' surgery is a specialized form of excision, which is usually preferred for squamous cell carcinomas. Cryosurgery is used to treat isolated lesions. Wide excision is used to remove full-thickness skin in the area of the lesion. A curettage and electrodissection procedure scrapes away cancerous tissue and helps to destroy the remaining tumor tissue by applying an electric probe. The registered nurse is teaching a student nurse about providing the emotional support to a patient with psoriasis. Which statement made by the student nurse indicates the need for further teaching? 2 Touch, more than any gesture, demonstrates the acceptance of the person with the skin problem, so the nurse should not wear gloves during social interactions. Appearance may be altered due to psoriasis, so the patient should be informed about the possibility of their appearance being altered. Placing a hand on the patient's shoulder when explaining a procedure demonstrates the acceptance of that person. Encouraging the patient to express his or her feelings about the disease will help with his or her emotional status. Which condition may trigger recurrence of herpes simplex virus (HSV) infection in an otherwise healthy
male? 1 Fatigue is a stressor that may trigger recurrence of HSV infection in an otherwise healthy male. Menses is a stressor for HSV infection for healthy female. Bell's palsy and eye infections are complications of Herpes zoster but not triggering factors. Which skin infection is associated with postherpetic
neuralgia? 1 Shingles is associated with postherpetic neuralgia, as the virus resides in the dorsal root ganglia. Cellulitis, furuncle, and folliculitis may not be associated with postherpetic neuralgia, as the organisms do not reside in the dorsal root ganglia. Which is a common area for candidial infections to
occur? 3 The vagina is a common area for candidial infections. The neck, hands, and abdomen may not be associated with candidial infection. Herpes zoster and dermatophytoses can be seen on the neck, hands, and abdomen. Which is a synonym of "athlete's foot"? 1
What is the triggering factor for the recurrence of herpes simplex skin infection? 2 Fever is a triggering factor for the recurrence of herpes simplex skin infections. Cold, cough, and headache may not be associated with herpes simplex infection. A registered nurse is precepting a student nurse who is educating the parents of a
child with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the nursing student's statements requires correction? 4 To prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) infection, the student nurse will teach the patient's parents precautions. The parents should ensure the patient takes all of the prescribed antibiotics, even if the dosage continues after the wound has appeared to heal. The other statements are correct. The child should avoid close contact with others and stay off upholstered furniture. The parents should also change the bandage any time drainage has seeped through it. Which
organism is associated with "hitch-hiking" infestation? 2 Which type of allergy is associated with linear streaks of vesicles? 1 Having an allergy to plants such as poison ivy is associated with linear streaks of vesicles. Latex, nickel, and toothpaste allergies are associated with localized eczematous eruptions that have well-defined, geometric margins. Which skin inflammation is often relieved by increasing exposure to sunlight? 1 Psoriasis is an autoimmune disorder that leads to increased skin cell production. Increasing the amount of sunlight exposure slows down the process. Atopic dermatitis is made worse by dry skin and allergies. Contact dermatitis becomes worse when the skin has direct contact with the allergen. The cause of nonspecific eczematous dermatitis is not always known; therefore, treating the cause includes topical creams and ointments. Which skin infection is associated with a typical "satellite lesion"?
3 " Satellite lesions" are erythematous macular eruptions that occur with isolated pustules or papules at the border. This typical feature is associated with candidiasis. Shingles is a skin infection caused by the varicella-zoster virus and does not have satellite lesions. The infection follows the path of the affected nerve. A furuncle is a skin infection caused by bacteria, involving deeper portions of the follicle. These are characterized by erythematous lesions filled with pus. Dermatophytosis is a fungal infection characterized by serpiginous patches Which type of lesion occurs as a result of necrosis? 1 In cutaneous anthrax, the lesion first appears as a vesicle with raised borders. After a few days, necrosis is seen in the center of the lesion, which eventually forms eschar. A papule is a small, firm, elevated lesion less than 1 cm in diameter. A vesicle is the early lesion of cutaneous anthrax that appears red in color. A macule is a flat lesion less than 1 cm in diameter. Its color is different from that of the surrounding skin, which is most often white, red, or brown. Which description is characteristic of a wound that is healing by third intention? 3 A potentially infected surgical wound heals by third intention. The wound is debrided and left open for several days until the inflammation subsides. The wound is then surgically closed. A wound that is made aseptically has minimal tissue destruction and begins to heal as soon as the edges are approximated by close sutures or staples; this wound heals by first intention. A chronic wound with tissue damage such as a pressure injury with extensive damage cannot be smoothly approximated. The wound is left open and left to heal from inside out. Scar tissue is extensive and healing is prolonged; this wound heals by second intention. Which process occurs in the third intention of wound healing? 1 Removal of debris and exudate is done in third intention with healing after a reduction in inflammation; the wound is then closed surgically. The elimination of dead space in a closed wound is done in first intention wound healing, which would shorten the phase of tissue repair. The inward pulling of wound edges that occurs along the path of least resistance is called contraction, which occurs in second intention. The replacement of dead tissue with scar tissue represents granulation; this occurs in second intention. A patient who is receiving drug therapy for urticaria reports an increasing sedative effect. The patient admits to consuming alcohol on a daily basis. Which category of medication could be the reason for this condition? 2 Antihistamines show increasing sedating effects when used concomitantly with alcohol due the depressant actions of both drugs on the central nervous system. Antihistamines such as diphenhydramine are prescribed to cure urticaria. Antibiotics such as topical bacterial agents are used to treat any debris in the wound. Cytotoxic drugs cause impaired cellular proliferation and are contraindicated in wound healing. Non-steroidal anti-inflammatory drugs cause an altered inflammatory response that may prolong the wound healing. The nurse is caring for a patient with a loss of tissue integrity. The diagnostic reports reveal damage to the dermis and subcutaneous tissue. What is the name of the process that will replace the damaged tissue? 1 Loss of tissue integrity that occurs due to damage to the deeper layers of dermis and subcutaneous tissue is a characteristic feature of a deep-partial and full-thickness wound. Granulation replaces damaged tissue with scar tissue and aids in wound healing. Contraction involves the pulling of wound edges inward along the path of least resistance. Resurfacing involves regrowth across the open area. Re-epithelialization involves the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis. A patient with chronic wounds is worried about treatment costs. What nursing tips for home care may be of help to the patient? Select all that apply. 3,5 Because caring for a chronic wound can be expensive, the nurse can tell the patient and his or her caregiver to use clean tap water and nonsterile supplies and to thoroughly wash their hands before touching supplies. Buying only sterile products is costly and unnecessary. If supplies are reusable, it would be too costly and wasteful to discard them after one use. Nonsterile items may be reused but need to be properly cleaned before the reuse. Which condition is characterized by the presence of a rash of white or red edematous papules? 3 Urticaria is characterized by the presence of rash of white or red papules or plaques of various sizes. Pruritus is characterized by itching. Trauma is characterized by the presence of cuts or bruises. Pressure injuries are characterized by the presence of red skin and blisters. Which process involves the replacement of damaged tissue with scar tissue that aids in wound healing? 1 Granulation involves the replacement of dead tissue with scar tissue that aids in healing. Contraction involves pulling the wound edges along the path of least resistance with the help of fibroblasts. Resurfacing involves regrowth across the open area. Re-epithelialization involves the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis. Which factor may cause a systemic altered inflammatory response? 1 Leukemia may cause a systemic altered inflammatory response by systemic inhibition of the leukocytic response, which results in an impaired host resistance to infection. Heart failure and hypovolemia may cause impaired cellular proliferation. Lymphedema may cause a local altered inflammatory response. A nurse is assessing a patient with incontinence. Which substances may be responsible for skin breakdown in the patient? Select all that
apply. 1,2,4,5 Prolonged contact with urea, yeast, bacteria, and enzymes in an incontinent patient may increase the risk of skin breakdown. Such substances are irritants and can destroy the integrity of the skin barrier. Nitrogen is not an element responsible for skin breakdown in the patient who is incontinent. What should the
nurse include in the plan of care when a patient reports itching? 2 Itching occurs when chemical agents or chemical mediators such as histamine act on itch receptors. Therefore, the nurse should implement measures to prevent dry skin, protect skin integrity, and promote sleep. This would include keeping the fingernails trimmed and filed to prevent skin tearing from scratching. The room should be kept cool to promote comfort and decrease itching. Patients with dry skin should shower every other day to prevent skin dryness. Herbal teas (not iced tea) can be used at bedtime to promote sleep and decrease itching. A patient has pruritus. Which measure is used to reduce skin
damage from scratching and prevent secondary infection? 2 For patients with pruritus, trimming the fingernails short with smooth edges can reduce skin damage from scratching and prevent secondary infection. Cool sleeping environment along with comfort measures such as a cool shower and application of moisturizers may help promote sleep. Wearing mittens or splints at night helps to prevent inadvertent scratching during sleep. Astringents can dry out the skin further, making pruritus worse. Which processes are required for restoring skin integrity? Select all that apply. 2,4,5 After injury, the body restores skin integrity through three processes - granulation, re-epithelialization, and wound contraction. In granulation, the damaged tissue is removed and filled with scar tissue. In re-epithelialization, the production of new skin takes place. In wound contraction, the wound size decreases and fibroblasts deposit new collagen to replace the damaged tissue. Closing of the wound occurs in wound contraction. Maturation and inflammation are phases of wound healing and not the processes involved in wound healing. What is the best way for the nurse to prevent a patient's stage I pressure injury from advancing to stage II? 3 Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this patient's pressure injury. Reddened areas should never be massaged. Padding the injury may not be appropriate. An egg crate mattress may be suggested but is not the best option. A patient is diagnosed with urticaria. Which factor is responsible for this condition? 1 Urticaria (hives) is the formation of white or red edematous papules or plaques of different sizes. It is caused by exposure to an allergen which releases histamine in the dermal tissue. Lesions, or wheals, occur because of blood vessel dilation and leakage of plasma proteins. Perspiration can cause pruritus. Exposure to ultraviolet light can lead to sunburn. Non-alkaline soap is used to prevent dry skin. The nurse instructs a patient at high risk for pressure injuries to avoid having
any reddened areas massaged. Why does the nurse recommend this? 4 Massage to reddened skin areas can damage capillary beds and increase tissue necrosis. Massage does not cause irritation, bleeding, or inflammation. Which condition is associated with
pruritus? 2 Liver disease increases the buildup of bilirubin in the skin, which stimulates itch receptors and may cause pruritus (itching). Thrombosis, arteriosclerosis, and diabetes mellitus may cause altered inflammatory responses and hamper wound healing, but are not directly associated with pruritus. What
systemic disease causes itching without skin lesions? 3 Liver disease is a systemic disease that causes itching without skin lesions due to excess bilirubin in the skin stimulating the itch receptors. Uremia, leukemia, and pulmonary insufficiency are systemic diseases that affect the wound healing process. Which event
takes place during the maturation phase of wound healing? 4 The maturation phase is the third phase of wound healing. It begins as early as 3 weeks after injury and may continue for a year. In the maturation phase, collagen is reorganized to provide greater tensile strength. In the proliferative (second) phase of wound healing, fibrin strands form a scaffold or framework, and later, epithelial cells grow over the granulation tissue bed. The inflammatory (first) phase of wound healing is marked by white blood cells (especially macrophages) migrating to the wound. The nurse is evaluating the effectiveness of interventions for pressure injury management. Which
diagnostic test result with an increased level indicates patient progress and effective health care team collaboration? 3 Albumin measures protein, which is necessary for healing; increased serum albumin indicates successful collaboration with the dietitian. Calcium, hematocrit, and WBC readings do not relate to successful pressure injury management. While assessing a patient with epilepsy, the nurse finds diffused redness and large blisters on the oral mucosa. Which is the priority nursing intervention? 1 Diffused redness and large blisters are the typical clinical signs of toxic epidermal necrolysis (TEN). Barbiturates that are used in treating epilepsy are one of the most common causes of TEN, therefore, discontinuing the medication is the priority intervention in this situation. Monitoring the body temperature, fluid intake and output are performed at the bedside, but not a priority intervention to treat redness and blisters. Topical antibacterial drugs are administered to suppress the bacterial growth of causative organisms until healing is noticed. During morning rounds, the nurse discovers that an older adult patient has been incontinent during the night. To protect the skin, what does the nurse do first? 1 Cleaning and drying the patient to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the patient in a side-lying position can all be done after the patient has been cleaned. A patient with chronic skin disorders complains of loss of vision. Which assessment finding made by the nurse confirms this diagnosis? Select all that apply. 1,2 Crusts and vesicles are the typical clinical features of Stevens-Johnson syndrome. Loss of vision is seen in severe conditions of Stevens-Johnson syndrome. Erythema is associated with toxic epidermal necrolysis (TEN). Both TEN and Stevens-Johnson syndrome are drug-induced and immunological reactions, so these findings cannot confirm the diagnosis. A patient tells the nurse, "My skin always looks dry even after I apply lotion." How should the
nurse respond? 1 Bathing in lukewarm water helps stimulate the release of oils from the sebaceous glands. This will help keep the skin moist and prevent dryness. Avoiding nylon stockings helps reduce the perspiration in the feet, legs, and genital area, thereby preventing bacterial infections and a bad odor. Leaving oil from soap on the skin will increase skin dryness. Wearing full-length pajamas during sleep may decrease the likelihood of the patient scratching the skin because of dryness; however, it will not address the dry skin itself. A patient with psoriasis who is on biologic
therapy has developed an infection. What would be the priority nursing interventions to treat this patient? Select all that apply. 1,3 The nurse should discontinue the medication and notify the primary health care provider if the patient develops an infection during treatment with biologic therapy. The nurse should not advise the patient to use antibiotics and to undergo complete blood test. These interventions should be performed by the primary health care provider. Physical examination may or may not be performed by the primary health care provider, but it is not a priority nursing intervention. Arrange the events of the proliferative phase of wound
healing in the correct sequence. The proliferative phase is the second phase of wound healing. It begins about the fourth day after injury and lasts 2 to 4 weeks. First, fibrin strands form a scaffold or framework. Then mitotic fibroblast cells migrate into the wound and stimulate the secretion of collagen. Collagen, together with ground substance, builds tough and inflexible scar tissue. Next, capillaries in areas surrounding the wound form "buds" that grow into new blood vessels. Capillary buds and collagen deposits form the "granulation" tissue in the wound, and the wound contracts. Finally, epithelial cells grow over the granulation tissue bed. The nurse is assessing a patient who is suspected to have tinea pedis. Which question asked by the nurse would be most appropriate to confirm the diagnosis? 4 Tinea pedis is also known as athlete's foot; it is a fungal infection. Sharing athletic equipment with an infected person may spread the infection. A history of recent skin trauma is usually associated with cellulitis, which is a bacterial infection. The presence of a similar lesion previously may be an indication for herpes zoster. Systemic symptoms after infection are usually seen in cellulitis and herpes zoster. A patient has an odorous purulent wound. How does the nurse best support this patient? 1 Frequent dressing changes help the patient feel clean. A diet high in protein would not be directly helpful for this patient. Whirlpool therapy may not be appropriate for this patient. Room deodorizers do not address the source of the problem and may be offensive to the patient and the family. What causes urticaria?What causes urticaria? Urticaria occurs when a trigger causes high levels of histamine and other chemical messengers to be released in the skin. These substances cause the blood vessels in the affected area of skin to open up (often resulting in redness or pinkness) and become leaky.
Which hypersensitivity reaction occurs in urticaria?Immunologic contact urticaria is a type 1 hypersensitivity reaction mediated by IgE antibodies specific to the eliciting substance or antigen. Once the IgE antibody binds to the antigen, vasoactive substances such as leukotrienes, prostaglandins, and histamine are released by mastocytes and basophils.
What type of hypersensitivity reaction is responsible for hives urticaria and allergies quizlet?Type I hypersensitivities include atopic diseases, which are an exaggerated IgE mediated immune responses (i.e., allergic: asthma, rhinitis, conjunctivitis, and dermatitis), and allergic diseases, which are immune responses to foreign allergens (i.e., anaphylaxis, urticaria, angioedema, food, and drug allergies).
Does benadryl help with allergic reactions?An antihistamine pill, such as diphenhydramine (Benadryl), isn't enough to treat anaphylaxis. These medications can help relieve allergy symptoms, but they work too slowly in a severe reaction.
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A patient is diagnosed with urticaria which factor is responsible for this condition Quizlet
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