A client with a severe cellulitis on the left hand was ordered to have cultures done on the affected area. After few days, the culture report was released. The nurse understands that which of the following organisms is not part of the normal flora of the skin?
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Solution
Campylobacter jejuni.
Campylobacter jejuni is found in the intestines and is one of the most common causes of diarrheal illness.
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 include fruits and vegetables in my meal plan.”
The beneficial nutrients found in fruits and vegetables are essential in the wound healing process.
Option A: The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair).
Option B: If the client’s foot feels cold, circulation is impaired, thus inhibiting wound healing.
Option D: For effective tissue healing, adequate intake of protein is needed.
Nurse Jeff is performing skin assessment on a client with a facial lesion. It appears as a well-defined, red, scaling, thickened bump. This type of skin lesion refers to?
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Solution
Squamous cell.
A squamous cell carcinoma is characterized by a well-defined, red, scaling, thickened bump on the sun-exposed skin such as the face, ears, neck, lips, and backs of the hands.
A nurse is developing a care plan for a client suffering from shingles. Which of the following cranial nerve should the nurse assess as part of the client’s care?
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Solution
Cranial nerve number VII
A potential complication of shingles is Bell’s palsy which can be assessed by the seventh cranial nerve function.
A female client went to the emergency department states that she is having burning and intense itching on the skin. A further assessment made by the nurse notes that the client is having red and white patches in the mouth. Based on this, the nurse understand that the client is most likely is suffering from?
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Solution
Candida Albicans.
Candida albicans is a superficial infection of the skin and mucous membranes. Assessment of this disorder includes red and irritated skin appearances that itches and burns & red and whitish patches on the mucous membranes of the mouth.
Option A: Shingles appears as unilateral clustered skin vesicles.
Option B: Erysipelas is characterized by a tender, intensely erythematous, indurated plaque with a sharply demarcated border.
Option C: Eczema is a skin condition where patches of skin become inflamed, itchy, red, cracked, and rough.
The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply
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Solution
The nurse who never had German Measles, C. The nurse who never had mumps, D. The nurse who never had roseola.
Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus for chicken pox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.
A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include:
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Solution
A skin infection into the subcutaneous tissue and dermis.
Cellulitis is an infection into deeper dermal and subcutaneous tissue that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces.
Option D: Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.
A client has been taking prednisone (Deltasone) 20 mg once a day to treat severe seborrheic dermatitis. Which of the following assessment findings is of most concern?
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Solution
Complaints of epigastric pain.
Complaints of epigastric pain indicate that the client might be suffering from peptic ulcers, which require the addition of the use of antacid such as proton pump inhibitor (Nexium).
Options B, C, and D are symptoms related to the use of prednisone but are not clinically significant when steroids are used for limited periods and do not require treatment.
A 30-year old woman who has been taking isotretinoin (Accutane) to treat severe cystic acne make all these statements while being seen for a follow-up examination. Which statement is of most concern?
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Solution
“My husband and I are thinking of starting a family soon.”
Isotretinoin (Accutane) is associated with a high incidence of birth defects, it is important that the client stops using the medication at least a month before attempting to become pregnant.
Options A and C: Poor night vision and nausea are possible adverse effects of isotretinoin that would require further assessment but are not as urgent as discussing but are not as urgent as discussing the fetal risks associated with this medication.
Option D: The client’s concern about the effectiveness of the medication should be addressed, but this is a low-priority intervention.
A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed one (1) week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion?
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Solution
Melanoma is highly metastatic.
Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This cancer is highly metastatic, and prognosis depends on early diagnosis and treatment.