A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin?
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Solution
Escherichia coli (E. coli)
E. coli normally is found in the intestines and constitutes a common source of infection of wounds and the urinary system. The other microbes listed are part of the normal flora of the skin.
A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
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Solution
Systemic lupus erythematosus (SLE)
An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia would be manifested by pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.
A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be:
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Solution
Net-like appearance
Reticular skin lesions resemble a net in appearance. Annular lesions are ring-shaped, whereas linear lesions appear in a straight line. Arciform lesions are shaped like an arc.
An older client’s physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin?
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Solution
Cherry angioma
Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red–colored lesion on the trunk or extremities. Spider angiomas have a bright red center with legs that radiate outward. These lesions commonly are seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Purpura results from hemorrhage into the skin.
A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?
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Solution
Ecchymosis
Ecchymosis is a type of purpuric lesion and also is known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
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Solution
Urine output of 20 ml/hour
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client’s PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.
While in a skilled nursing facility, a female client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
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Solution
“All family members will need to be treated.”
When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
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Solution
pressure-like pain.
Severe pressure like pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
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Solution
range of motion.
To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.
The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching?
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Solution
“I’ll eat plenty of fruits and vegetables.”
For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair). If the client’s foot feels cold, circulation is impaired, thus inhibiting wound healing.