NCLEX Practice Exam for Skin and Integumentary Diseases Part 1

EXPLANATION

✔Correct answer:

Shield the graft from direct sunlight. Protecting the newly healed skin graft from direct sunlight is critical for its long-term success and appearance. Newly grafted skin is highly sensitive to sunlight, and UV radiation can cause discoloration, hyperpigmentation, or even damage to the fragile graft, delaying healing or permanently affecting the graft’s appearance. Sun exposure can also increase the risk of skin cancer in grafted areas, where the skin has already been compromised. Therefore, Ms. Lewis should be advised to cover the grafted area with clothing or apply sunscreen with a high SPF (30 or above) when going outdoors.

The grafted skin should be protected for several months to a year, depending on the physician’s recommendations, as it continues to strengthen and integrate with the surrounding tissue.

Think of the skin graft like a new patch of fabric—if exposed to harsh sunlight, it can fade and weaken. Keeping it covered helps protect its strength and appearance as it heals.

Nurse Sarah should emphasize the importance of avoiding direct sun exposure and provide additional guidance on how to care for the graft site at home.

• Sun protection: Advise Ms. Lewis to avoid direct sunlight, wear protective clothing, and apply sunscreen with SPF 30 or higher to the graft site when outdoors.
• Monitor for complications: Instruct Ms. Lewis to monitor the graft site for signs of infection or rejection, such as redness, swelling, increased pain, or drainage, and to report these immediately to her healthcare provider.
• Follow up care: Encourage regular follow-up visits with her healthcare provider to assess the healing of the graft.

✘Incorrect answer options:

Use cosmetic techniques to conceal the graft. While cosmetic techniques may eventually help with appearance concerns, cosmetic camouflage is not the priority during the early stages of graft recovery. The primary focus should be on protecting and healing the graft.

Keep up with physical therapy exercises. Physical therapy exercises may be essential, especially if the graft was applied near joints, to prevent contractures and maintain mobility. However, the most critical instruction is to protect the graft from sunlight, which can cause serious damage to the healing skin.

Apply moisturizing lotion to the graft site. Moisturizing can be helpful once the graft has healed, but during the early recovery period, applying lotions may irritate the graft or interfere with healing. This is not the most important aspect of care immediately after the procedure.

EXPLANATION

✔Correct answer:

Applying a topical treatment. For many skin conditions, the first-line treatment typically involves topical medications. Topical treatments allow direct application to the affected area, providing localized action with minimal systemic side effects. These treatments can include corticosteroids, antifungals, antibiotics, or emollients, depending on the underlying condition (e.g., dermatitis, fungal infections, bacterial infections, etc.).

Topical therapies are often preferred as an initial approach because they effectively target the problem area and reduce the risk of complications associated with systemic treatments. For example, mild-to-moderate cases of dermatitis might be treated with topical corticosteroids, while localized bacterial infections like impetigo could be treated with topical antibiotics.

Think of a topical treatment like applying a bandage directly over a cut—it goes right to the source, addressing the issue locally without affecting the rest of the body.

Nurse Sarah should educate Mr. Leonard on the proper application of topical medications, such as cleaning the affected area before applying the treatment and following the prescribed frequency and duration of use. She should also monitor the skin's response to the topical treatment and notify the physician if the condition worsens or does not improve.

• Teach proper application: Instruct the patient to clean and dry the affected area before applying the topical medication and to use it exactly as prescribed.
• Monitor for improvement: Observe for signs of healing or worsening, and ensure the patient follows up as necessary.
• Educate on side effects: Some topical treatments may cause local irritation or allergic reactions. Ensure the patient is aware of this and knows when to seek help.

✘Incorrect answer options:

Administering an I.V. corticosteroid. I.V. corticosteroids are generally reserved for severe, systemic inflammatory responses, such as in cases of severe allergic reactions or autoimmune flares. For most localized skin conditions, a topical corticosteroid would be used first before considering systemic options.

Administering an I.V. antibiotic. I.V. antibiotics are typically used for serious, widespread infections like cellulitis or sepsis. For localized skin infections, oral or topical antibiotics would be the first line of treatment.

Prescribing an oral antibiotic. While oral antibiotics may be prescribed for more extensive or severe bacterial skin infections, they are generally not the initial treatment for localized skin conditions unless a bacterial cause is confirmed or suspected to be widespread.

EXPLANATION

✔Correct answer:

Ring or donut. Ring or donut-shaped cushions are often mistakenly thought to relieve pressure, but they can actually impair circulation in the area they're meant to protect. These cushions create uneven pressure distribution, focusing more pressure on the surrounding tissues while leaving the center of the cushion unsupported. This leads to increased pressure around the edges, potentially causing restricted blood flow, tissue ischemia, and a higher risk of pressure injury in vulnerable patients, such as those who are wheelchair-bound or immobile for long periods.

Donut cushions were historically used for pressure relief but are no longer recommended in clinical practice due to their potential to cause harm rather than prevent it.

Imagine trying to sit on a tire. Your weight would be unevenly distributed around the edges, putting extra pressure on certain spots while leaving other areas unsupported. This uneven pressure can cut off circulation and lead to problems, much like how a donut cushion can harm rather than help skin health.

To prevent pressure injuries and promote circulation, Nurse Daniel should focus on using devices that evenly distribute pressure and reduce friction and shear. He should also ensure regular repositioning of the patient to prevent prolonged pressure on any one area.

• Regular repositioning: Encourage the patient to shift their weight frequently or assist with repositioning every two hours to relieve pressure on vulnerable areas.
• Use pressure-relieving devices: Devices such as gel cushions, foam mattresses, and specialized support surfaces (e.g., air mattresses) can help distribute pressure more evenly.
• Skin assessment: Perform frequent skin assessments to identify early signs of pressure injury, such as redness, warmth, or skin breakdown.

✘Incorrect answer options:

Polyurethane foam mattress is designed to distribute weight evenly and reduce pressure points, making it an effective option for preventing pressure injuries and promoting circulation.

Gel flotation pad works by distributing body weight over a larger surface area, reducing pressure and helping to prevent skin breakdown. It is commonly used for wheelchair-bound patients to prevent pressure ulcers.

Waterbed helps in redistributing pressure across the body. The fluid-filled mattress minimizes localized pressure and reduces the risk of pressure injuries by allowing the patient to "float" in a more even distribution of body weight.

EXPLANATION

✔Correct answer:

Herpes simplex infection during early pregnancy can lead to spontaneous abortion or premature birth. Herpes simplex virus (HSV) infections, particularly primary infections during early pregnancy, can pose significant risks to both the mother and the developing fetus. HSV-2, which typically causes genital herpes, is associated with an increased risk of complications during pregnancy, such as spontaneous abortion, premature birth, or congenital herpes if the virus is transmitted to the fetus. Neonatal herpes can be life-threatening and is most often acquired during vaginal delivery if the mother has active lesions at the time of birth.

Herpes simplex infections can also lead to fetal anomalies and neurological complications if transmitted vertically (from mother to baby). Early detection and management, including antiviral therapy, are crucial for reducing these risks.

Think of the herpes virus like a wildfire during pregnancy. If it happens early (first trimester), it can cause more harm to the pregnancy (like a fire damaging the foundation of a building). Proper management is like using firebreaks to limit damage and protect the pregnancy.

Nurse John should emphasize the importance of prenatal care and antiviral treatments to manage herpes simplex infections in pregnancy. Additionally, safe delivery options (such as cesarean section) can help prevent neonatal transmission if active genital lesions are present during labor.

• Monitor for symptoms: Pregnant women with herpes should be closely monitored for symptoms of an active outbreak, especially during the third trimester, when the risk of neonatal transmission is highest.
• Antiviral therapy: Prescribing antiviral medications like acyclovir in the third trimester can reduce the likelihood of an outbreak and decrease viral shedding.
• Delivery planning: If active lesions are present during labor, a cesarean section may be recommended to prevent neonatal transmission.

✘Incorrect answer options:

Genital herpes simplex presents as painless, fluid-filled blisters that ulcerate and heal in 3 to 7 days. This statement is incorrect because genital herpes lesions are typically painful, not painless. The lesions initially present as fluid-filled blisters that rupture, leaving painful ulcers that can take 2 to 4 weeks to heal, particularly during the first outbreak. Subsequent outbreaks are usually milder and shorter in duration.

Herpetic keratoconjunctivitis typically affects both eyes and causes systemic symptoms. This is incorrect because herpetic keratoconjunctivitis (herpes infection of the eye) typically affects only one eye and primarily causes local symptoms such as pain, photophobia, and blurred vision. Systemic symptoms are not common in localized ocular herpes.

A client with active genital herpes lesions can still have sexual contact but must use a condom. This statement is false and dangerous advice. Individuals with active genital herpes should avoid sexual contact entirely until the lesions have completely healed. Even with condom use, the virus can still be transmitted through areas not covered by the condom. Sexual abstinence during outbreaks is the safest approach to prevent transmission.

EXPLANATION

✔Correct answer:

Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days. The most appropriate treatment for primary herpes genitalis is the use of antiviral medications such as acyclovir. Acyclovir is specifically effective against the herpes simplex virus (HSV), which causes genital herpes. In this case, the instruction to apply acyclovir ointment every 3 hours, six times a day, is a typical regimen used to control viral replication, reduce symptoms, and promote healing of the lesions during an outbreak. The treatment helps to manage the acute phase of herpes and can shorten the duration of symptoms.

Topical antivirals like acyclovir are useful for managing localized outbreaks of herpes, though oral antiviral therapy (e.g., acyclovir, valacyclovir, or famciclovir) is often preferred for more systemic control, especially in primary infections.

Think of acyclovir like a repair team sent to a broken fence (the herpes lesions). Applying it regularly helps the repair team keep the damage under control (reduce viral spread) and speeds up fixing the fence (healing the lesions).

Nurse Carla should also emphasize the importance of hygiene and educating the patient about avoiding sexual contact during active outbreaks to prevent transmission. The patient should be informed that while antiviral therapy helps manage symptoms, herpes is a chronic condition with no cure, and outbreaks may recur.

• Ensure proper application: Instruct the patient to apply the ointment directly to the lesions and to wash hands thoroughly before and after application to prevent spreading the virus.
• Encourage antiviral compliance: Remind the patient to use the medication as prescribed for the full course, even if symptoms improve earlier.
• Advise on safe sexual practices: Inform the patient to avoid sexual activity during outbreaks and to use barrier protection during asymptomatic periods to reduce transmission risk.

✘Incorrect answer options:

Use one applicator of terconazole intravaginally at bedtime for 7 days. This is incorrect because terconazole is an antifungal medication used to treat vaginal yeast infections (candidiasis), not herpes simplex virus infections. It has no effect on viral conditions like herpes.

Use one applicator of tioconazole intravaginally at bedtime for 7 days. Similar to the above, tioconazole is also an antifungal used for vaginal yeast infections. It is not used to treat viral infections such as herpes simplex.

Massage sulconazole nitrate gently into the lesions twice a day. Sulconazole is another antifungal medication used to treat conditions like athlete’s foot or jock itch. It is not appropriate for treating viral infections such as herpes simplex.

EXPLANATION

✔Correct answer:

"It locks in moisture by preventing water from evaporating from the skin." Emollients are moisturizing agents that help soften and hydrate the skin, and they are most effective when applied right after bathing. The reason for this is that bathing increases the skin's moisture content, and applying an emollient immediately afterward helps trap that moisture by creating a protective barrier on the skin's surface. This barrier prevents transepidermal water loss (the evaporation of water from the skin), helping to maintain hydration and relieve pruritus (itching).

For patients like Ms. Parker with pruritus, keeping the skin well-hydrated is key to reducing itching and preventing further irritation or damage from scratching.

Think of your skin like a sponge that absorbs water. If you coat the sponge with a plastic wrap (emollient) right after soaking it, the water stays in the sponge longer, keeping it soft and hydrated.

Nurse Olivia should instruct Ms. Parker to gently pat her skin dry after bathing, leaving some moisture on the skin before applying the emollient. This will enhance the effectiveness of the treatment and help soothe the itching.

• Apply emollient immediately: Instruct the patient to apply the emollient within 3 minutes of bathing to lock in moisture.
• Gently pat dry: Encourage the patient to pat her skin dry (rather than rubbing) after bathing to avoid irritation and leave a thin layer of moisture.
• Apply liberally: Advise the patient to apply the emollient liberally to all areas of dry or itchy skin.

✘Incorrect answer options:

"It helps make your skin feel soft." While emollients do soften the skin, the primary benefit of applying them right after bathing is locking in moisture, not just making the skin feel soft.

"It reduces the chances of your skin cracking." While maintaining hydration can reduce the risk of cracking, this is not the main reason for applying emollients immediately after bathing. The primary function is to trap moisture and prevent water loss.

"It helps prevent skin inflammation." Emollients can help soothe inflammation by maintaining the skin's barrier, but this is not the main purpose of applying the product after bathing. The focus is on locking in moisture to hydrate the skin and reduce pruritus.

EXPLANATION

✔Correct answer:

"Always apply sunscreen, even on cloudy days." While all the options provide valid advice for protecting against UV damage, applying sunscreen daily is the most critical and consistent method of preventing skin damage from UV rays, regardless of whether the sun is directly visible. Ultraviolet (UV) radiation can penetrate clouds and still cause skin damage even on overcast days. Therefore, patients need to understand that sunscreen should be applied not only during direct sun exposure but also when UV rays are less obvious, such as on cloudy or cool days.

Applying a broad-spectrum sunscreen that protects against both UVA and UVB rays, with a sun protection factor (SPF) of 30 or higher, is crucial in reducing the risk of sunburn and long-term skin damage, such as premature aging and skin cancer.

Think of sunscreen as a protective umbrella that shields you from the rain (UV rays). Even when the clouds are out and the sun isn’t shining directly, there might still be light rain falling (UV rays reaching your skin), so you need your umbrella (sunscreen) every day, not just when it's sunny.

Educating patients on proper sunscreen use is crucial in reducing skin damage risk. Additionally, emphasizing consistent sun protection strategies helps reinforce prevention behaviors in a broader context beyond sunny days.

• Daily Application: Instruct patients to apply sunscreen daily, even if it's cloudy or if they are indoors near windows, as UV rays can still cause skin damage.
• Proper Coverage: Encourage the use of a broad-spectrum sunscreen with SPF 30 or higher, applied 20-30 minutes before sun exposure and reapplied every two hours or after swimming/sweating.
• Other Precautions: Remind patients that sunscreen alone isn't enough—protective clothing, hats, and sunglasses are also important for complete UV protection.

✘Incorrect answer options:

"Avoid sun exposure between 1 to 4 p.m. when the sun is at its peak." While it is true that the sun is strongest around midday, typically from 10 a.m. to 4 p.m., and minimizing exposure during these hours can reduce the risk of sunburn, this is not always feasible for every patient. Applying sunscreen every day, regardless of time or weather, is more practical and effective overall.

"Choose sunscreen with a minimum SPF of 6." An SPF of 6 provides insufficient protection against UV rays. It is recommended to use sunscreen with a minimum SPF of 30, which blocks about 97% of UVB rays. Higher SPF offers more protection, though no sunscreen blocks 100% of UV rays.

"At the beach, stay in the shade to reduce the risk of sunburn." While seeking shade is a good practice, UV rays can still reflect off surfaces like sand and water, increasing the risk of sunburn. Even when in the shade, sunscreen should be applied for complete protection.

EXPLANATION

✔Correct answer:

Reposition him frequently to relieve pressure. The most effective way to prevent the development of pressure ulcers, especially in patients who are unable to reposition themselves, is to frequently reposition the patient to relieve pressure on vulnerable areas, such as the sacrum, heels, elbows, and hips. Regular repositioning, ideally every 2 hours, helps to distribute pressure more evenly across the body, preventing prolonged pressure on bony prominences that can lead to tissue ischemia, skin breakdown, and ultimately pressure ulcer formation.

Pressure ulcers, also known as bedsores, develop when constant pressure decreases blood flow to the skin and underlying tissues, leading to damage. Repositioning alleviates this pressure, ensuring that tissues remain adequately perfused and reducing the risk of ulcer formation.

Think of sitting on a chair for hours without moving—eventually, you'll feel discomfort and numbness because of the constant pressure on the same spot. If you shift your position regularly, you prevent that discomfort, just like repositioning helps prevent pressure ulcers.

Nurse Kim should prioritize repositioning Mr. Howard according to a set schedule and use supportive devices such as pillows to help offload pressure. In addition, monitoring skin integrity and using specialized pressure-relief surfaces can enhance preventive care.

• Use a turning schedule: Reposition the patient at least every 2 hours to prevent prolonged pressure on the same areas.
• Inspect skin regularly: Perform frequent skin assessments, especially on bony prominences, to detect early signs of pressure injury such as redness, warmth, or breakdown.
• Utilize pressure-relieving surfaces: Use specialized mattresses, cushions, or pads to help distribute pressure evenly and protect high-risk areas.

✘Incorrect answer options:

Regularly perform passive range-of-motion (ROM) exercises. ROM exercises help maintain joint flexibility, prevent contractures, and promote circulation, but they do not specifically prevent pressure ulcers. While important for overall recovery, ROM exercises do not relieve pressure from bony prominences.

Limit the patient’s fluid intake. Fluid restriction is not recommended in preventing pressure ulcers. In fact, adequate hydration is crucial for maintaining skin integrity and promoting overall tissue health. Limiting fluids may actually increase the risk of skin breakdown due to dehydration.

Suggest the use of a footboard for support. A footboard can help maintain foot alignment and prevent foot drop, but it does not relieve pressure on bony areas or prevent pressure ulcers. Pressure relief and regular repositioning are the primary strategies for ulcer prevention.

EXPLANATION

✔Correct answer:

Ineffective airway clearance due to swelling in the respiratory passages. In a patient with upper torso burns, the highest priority is airway management, especially if there is any suspicion of burns near the face, neck, or chest. Burns in these areas can lead to swelling in the respiratory passages, compromising the patient's ability to breathe. The inflammatory response following burn injuries can cause edema in the upper airways, and smoke inhalation or heat exposure can exacerbate this, potentially leading to life-threatening airway obstruction.

Inhalation injuries or burns around the upper torso can lead to swelling in the airway, increasing the risk of ineffective airway clearance. The mucosal lining of the respiratory tract can become inflamed and edematous, which could block airflow. Immediate intervention, such as securing the airway (intubation if necessary), is critical because airway compromise can rapidly result in hypoxia or respiratory failure.

Imagine the airway as a tunnel that allows traffic (air) to flow freely. If debris or swelling (like in a burn) begins to block the tunnel, cars (oxygen) can no longer pass through, causing a traffic jam (breathing difficulty) that can be dangerous if not cleared quickly.

Nursing interventions focus on preventing airway obstruction, managing any existing swelling, and ensuring that oxygenation remains adequate. These interventions are critical in avoiding respiratory compromise that could arise from burn-related swelling or inhalation injury.

• Immediate Assessment: Continuously monitor airway patency, breathing sounds, and signs of respiratory distress.
• Oxygenation Support: Administer supplemental oxygen as needed and prepare for intubation if airway obstruction is suspected.
• Positioning: Elevate the head of the bed to decrease airway edema.
• Frequent Monitoring: Assess vital signs, including respiratory rate and oxygen saturation, frequently to detect early signs of hypoxia.

✘Incorrect answer options:

Limited physical mobility related to the injury. While limited mobility is an important issue in burn patients due to pain, tissue damage, and the risk of contractures, it does not take precedence over airway management. Addressing physical mobility comes after ensuring the patient’s breathing is stabilized.

Interrupted sleep pattern influenced by the hospital environment. An interrupted sleep pattern is a non-urgent nursing diagnosis in comparison to airway clearance. Although poor sleep can affect recovery, it is a lower priority when the patient’s life is potentially at risk due to airway compromise.

Risk for infection associated with compromised skin integrity. Burns significantly increase the risk of infection due to the loss of the protective skin barrier, and this is a critical aspect of burn care. However, infection management becomes a priority after ensuring the airway is secure, as respiratory issues are immediately life-threatening.

EXPLANATION

✔Correct answer:

Arm movements and range of motion. After the application of artificial skin for a full-thickness burn, it is critical to limit arm movements and range of motion for at least the first 7 days. This restriction allows the artificial skin to adhere securely to the wound and begin integrating with the underlying tissue without disruption. Movement could lead to shear forces or tension, which could cause the graft to shift or detach, jeopardizing the healing process.

During this early stage, immobilization of the affected area is essential to prevent mechanical stress on the graft. Once the graft is stable, the healthcare provider will typically guide the patient on gradually resuming range-of-motion exercises to prevent joint stiffness and contractures, but initial rest is necessary for proper graft adherence.

Think of the artificial skin like a freshly glued patch on fabric. If you keep moving or stretching the fabric too soon, the patch might come off before it fully sticks. The same goes for your arm—movement too soon could disrupt the graft.

Nurse Beth should educate Mr. Johnson about the importance of limiting arm movement during the first week after the procedure and ensure that he understands the gradual process of reintroducing activity. This helps prevent complications such as graft dislodgement or delayed healing.

• Encourage immobilization: Instruct the patient to limit movement of the affected arm and use any recommended slings or splints.
• Monitor graft integrity: Regularly assess the graft site for any signs of displacement, infection, or compromised healing.
• Reintroduce activity gradually: Once the graft is secure, work with the healthcare team to reintroduce range-of-motion exercises in a controlled manner.

✘Incorrect answer options:

Intake of protein-rich foods. Protein is essential for wound healing and tissue repair, particularly after a burn. Reducing protein intake would hinder the healing process. In fact, increasing protein intake is encouraged to support recovery from burns.

Time spent outdoors. While sun exposure should be minimized during recovery from burns, particularly to prevent damage to fragile healing skin, this is not the primary concern within the first 7 days post-graft. The immediate priority is to limit movement to ensure graft adherence.

Fluid consumption. Reducing fluid intake is not recommended. Burn patients often require increased fluid intake to compensate for fluid loss and to promote optimal healing. Adequate hydration is important for maintaining healthy skin and tissue repair.

EXPLANATION

✔Correct answer:

Use long, even strokes outward and downward, following the direction of hair growth. The correct technique for applying topical medications like dexamethasone cream involves using long, even strokes following the direction of hair growth. This minimizes skin irritation and helps ensure that the medication is applied evenly and gently, particularly on areas with hair. Rubbing the cream against the direction of hair growth can cause friction and irritation, potentially leading to folliculitis or discomfort.

Dexamethasone cream is a corticosteroid used to reduce inflammation and treat conditions such as dermatitis. Proper application helps ensure that the medication is absorbed effectively and that the patient receives the therapeutic benefits while minimizing irritation.

Imagine combing your hair. If you go in the direction your hair grows, it's smooth and comfortable. If you comb against it, it tugs and irritates. Applying cream in the direction of hair growth works the same way, helping the cream go on smoothly without irritation.

Nurse Jenny should also educate the patient about the proper frequency and amount of medication to apply, and she should monitor for any adverse reactions, such as skin thinning or irritation, especially with long-term corticosteroid use.

• Wash hands before and after application: To prevent contamination and ensure proper application.
• Apply a thin layer: A small amount of medication is usually sufficient, and over-application can increase the risk of side effects.
• Avoid occlusive dressings unless prescribed: Using occlusive dressings can increase the absorption of corticosteroids, which may lead to systemic effects if not monitored carefully.

✘Incorrect answer options:

Use a circular motion to enhance absorption. While circular motion may help in applying lotions evenly, corticosteroid creams like dexamethasone should be applied with smooth strokes in the direction of hair growth to minimize irritation.

Apply with an upward motion to improve blood flow to the area. Blood flow enhancement is not the goal of topical corticosteroid application. Upward strokes are unnecessary and could irritate the skin, particularly in areas with hair.

Use long, even strokes outward and upward, going against the direction of hair growth. Applying cream against the direction of hair growth can cause skin irritation and discomfort. It may also lead to issues like folliculitis due to disruption of hair follicles.

EXPLANATION

✔Correct answer:

All family members should undergo treatment. Scabies is a highly contagious skin infestation caused by the Sarcoptes scabiei mite, and it spreads easily through close personal contact and shared items like bedding and clothing. Even if some family members are not currently showing symptoms, they may still be infested, as the mites can take up to 4 to 6 weeks to cause noticeable itching and rashes. Therefore, to prevent reinfestation and stop the spread of the mites, all household members and close contacts should undergo treatment simultaneously, regardless of whether they are symptomatic.

Treatment typically involves the use of prescription topical medications, such as permethrin cream, applied to the entire body from the neck down. Bedding, clothing, and towels should also be washed in hot water or sealed in plastic bags for several days to kill any mites that may be present.

Think of scabies like a small infestation of insects in a house. Even if you only see the bugs in one room (one person with symptoms), the entire house (family) needs to be treated to ensure the infestation doesn’t spread or return.

Nurse Leah should instruct Ms. Turner on the importance of treating all family members at the same time and taking the necessary steps to clean the household to prevent reinfestation.

• Treat all household members: Ensure that all family members apply the prescribed treatment simultaneously, even if they aren’t showing symptoms yet.
• Clean household items: Advise Ms. Turner to wash all bedding, towels, and clothing in hot water and dry on high heat, or seal non-washable items in plastic bags for at least 72 hours.
• Monitor for symptoms: Family members should watch for itching or skin rashes, which can appear weeks after infestation, and seek treatment if necessary.

✘Incorrect answer options:

If anyone shows symptoms, they should see a physician immediately. While it is true that symptomatic individuals should seek treatment, scabies is highly contagious, and treatment should be provided to all close contacts, even if they are asymptomatic, to prevent reinfestation.

Avoid sharing towels and linens with family members. While avoiding the sharing of personal items is a good practice to help reduce transmission, this alone is not sufficient. All household members should undergo treatment to eliminate the infestation.

Once you're treated, your family members won't be at risk anymore. This is incorrect because scabies can spread easily within a household. Ms. Turner may have already transmitted the mites to her family members, and treatment for all household members is necessary to prevent ongoing transmission and reinfestation.

EXPLANATION

✔Correct answer:

Diarrhea. Diarrhea is a known potential side effect of acyclovir (Zovirax), an antiviral medication commonly used to treat herpes zoster (shingles) and other viral infections caused by herpes viruses. Acyclovir can cause gastrointestinal disturbances, including diarrhea, nausea, and abdominal pain. Nurse Ellen should inform the patient to monitor for any changes in bowel habits and report persistent or severe diarrhea, as it can lead to dehydration or electrolyte imbalances if not managed properly.

It’s important to remind the patient to stay hydrated, especially during the course of acyclovir treatment, as dehydration can exacerbate side effects and affect the body's ability to fight off the viral infection.

Think of acyclovir like a strong cleaner for your body’s "pipes" (digestive system). While it’s fighting off the virus, it can sometimes irritate the lining, causing your system to run too fast (diarrhea).

Along with monitoring for side effects, Nurse Ellen should also emphasize the importance of taking acyclovir as prescribed and completing the full course to prevent complications or worsening of the infection.

• Encourage hydration: Remind the patient to drink plenty of fluids to prevent dehydration, especially if diarrhea occurs.
• Monitor for side effects: Instruct the patient to report any severe gastrointestinal issues or other unexpected side effects to their healthcare provider.
• Educate on medication adherence: Reinforce the importance of taking the medication consistently, even if symptoms improve before the course is completed.

✘Incorrect answer options:

Palpitations are not commonly associated with acyclovir. This medication does not typically cause cardiac symptoms like palpitations. If palpitations occur, it is likely unrelated to acyclovir and should be evaluated further.

Dizziness can occur as a side effect of many medications, but it is not a frequent or notable side effect of acyclovir. If the patient experiences dizziness, it may be due to other factors or medications.

Metallic taste is more commonly associated with certain antibiotics or chemotherapy drugs, but not with acyclovir. This antiviral does not usually cause taste disturbances.

EXPLANATION

✔Correct answer:

It could cause the autografts to dislodge. After an autograft procedure—where skin is transplanted from one area of the patient's body to cover burn wounds—the grafts need time to adhere and heal properly. Exercising too soon can disrupt the newly applied grafts by causing shear forces or tension at the graft sites, leading to dislodgement of the grafts. During the first few days after an autograft, it’s crucial to immobilize the area and avoid any movement that could interfere with graft adherence.

Allowing the autografts to secure in place without movement helps ensure better graft survival, minimizes the risk of complications, and promotes faster healing. Typically, movement is restricted for the first 3 to 5 days after grafting, after which the healthcare provider may gradually reintroduce range-of-motion exercises to prevent contractures, but only under close supervision.

Imagine placing a patch on a leaky tire. If you keep moving the tire before the patch fully sticks, it might come off. Similarly, exercising too soon can dislodge the "patch" (autograft) before it has fully adhered to the skin.

Nurse Carla should instruct Ms. Harper to limit arm movement for the prescribed period to allow the grafts to adhere securely. Once the grafts are stable, she can begin gentle range-of-motion exercises under the guidance of a healthcare provider to prevent stiffness and contractures.

• Immobilization: Ensure the grafted area is properly immobilized and positioned to prevent movement and reduce the risk of dislodging the graft.
• Educate the patient: Explain the importance of resting the affected area to allow the grafts to heal and provide information on when safe exercises can resume.
• Monitor graft integrity: Regularly assess the graft sites for signs of dislodgement, infection, or compromised blood flow.

✘Incorrect answer options:

It might lead to increased swelling in the arms. While exercise could potentially lead to increased swelling postoperatively, the primary concern after a recent autograft is that movement could dislodge the graft. Controlling swelling is important, but it’s not the immediate reason for stopping exercise at this stage.

It could result in more severe scarring. Scarring is typically influenced by wound healing and the natural healing process, but early movement of the arms is more likely to disrupt the grafts rather than directly worsen scarring. Managing graft adherence takes priority in the early healing phase.

It might reduce blood flow to the fingers. Exercise, in fact, would increase circulation, not reduce blood flow. The issue here is not circulation, but movement affecting the grafted area. The grafts need time to adhere, and any unnecessary movement risks graft failure.

EXPLANATION

✔Correct answer:

24 hours. After receiving photochemotherapy (also known as PUVA therapy, which involves the use of a photosensitizing drug like psoralen followed by exposure to UVA light), Ms. Stevens must protect her eyes from ultraviolet (UV) light for at least 24 hours. The psoralen medication makes the skin and eyes more sensitive to UVA light, which increases the risk of cataracts and other eye damage if proper precautions are not taken. Wearing UV-blocking sunglasses both indoors and outdoors, even in low-light settings, is crucial during this period to prevent any harmful exposure to UV light.

Psoralens remain active in the body for around 24 hours after ingestion, which is why it's important to protect both the skin and the eyes for the full duration to avoid side effects.

Think of psoralen like sunscreen for your skin and eyes that lasts 24 hours. While it's active, you need to stay protected from the sun, just like you would with sunscreen to prevent burning or damage.

Nurse Rachel should provide Ms. Stevens with detailed instructions on wearing UV-blocking sunglasses continuously after her PUVA therapy and avoiding any unnecessary UV exposure during that time. It’s also important to remind her to avoid direct sun exposure to her skin, as her skin will be more prone to burns.

• UV protection for eyes: Instruct Ms. Stevens to wear UV-blocking sunglasses for 24 hours after taking the medication, even when indoors in well-lit areas.
• Limit sun exposure: Advise her to stay out of direct sunlight or cover her skin with protective clothing for the same period to prevent burns and skin damage.
• Follow-up: Ensure that Ms. Stevens knows the schedule for future treatments and understands all the protective measures to avoid long-term complications.

✘Incorrect answer options:

4 hours. This is too short of a time period to offer adequate protection. Psoralens remain active for up to 24 hours, so protection from UV light is necessary for a full day after treatment.

8 hours. While some increased protection is needed shortly after the medication, 8 hours is not sufficient for full eye protection post-treatment. Full shielding is required for 24 hours.

48 hours. Eye protection for 48 hours is not necessary. The photosensitizing effects of psoralens typically last for 24 hours, so protection beyond this period is not required.

EXPLANATION

✔Correct answer:

Scales. Scales are the most common type of secondary lesion seen in patients with psoriasis, a chronic inflammatory skin condition. Psoriasis is characterized by the rapid turnover of skin cells, leading to the buildup of thick, silvery-white scales on the skin's surface. These scales result from the abnormal shedding of dead skin cells (keratinocytes) and are a hallmark feature of the disease.

Psoriatic lesions usually appear as red, inflamed patches covered by these thick, scaly plaques. The scales can vary in size and thickness, often causing itching or discomfort for the patient.

Think of psoriasis scales like peeling paint on a wall. The skin cells build up and flake off, similar to how layers of paint can peel away when applied too thickly or too quickly.

When caring for patients with psoriasis, it is important to focus on symptom management and prevention of complications such as infection from skin breakdown. Treatment options often include topical therapies (e.g., corticosteroids or moisturizers), phototherapy, or systemic medications for more severe cases.

• Encourage Moisturization: Applying emollients can help reduce scaling and dryness, improving comfort for the patient.
• Teach About Triggers: Educate the patient about potential triggers for psoriasis flare-ups, such as stress, infection, or certain medications.
• Monitor for Infections: Scaly skin can crack, leading to possible bacterial infections. Proper skin care and hygiene are essential.

✘Incorrect answer options:

Crusts are hardened deposits of dried serum, blood, or pus, often seen in skin infections or after vesicles or pustules have ruptured. While psoriasis may cause cracked skin, crusts are not a defining feature of this condition.

Ulcers are deeper lesions that result from the loss of the epidermis and part of the dermis. They are typically associated with pressure injuries, vascular issues, or other severe skin conditions. Ulcers are not characteristic of psoriasis.

Scars form as a result of the healing process after tissue damage, typically from deep wounds or chronic injuries. Although scarring can occur in cases of severe skin trauma, psoriasis usually causes scales, not scars.

EXPLANATION

✔Correct answer:

"Make sure to wash your hands thoroughly to prevent spreading the infection to your eyes." Gonorrhea, caused by Neisseria gonorrhoeae, can be transmitted to other areas of the body, including the eyes, if proper hygiene is not maintained. Gonococcal conjunctivitis, a serious eye infection, can occur if the bacteria from genital secretions are accidentally transferred to the eyes, leading to redness, swelling, and potential damage to vision. For this reason, it’s critical to emphasize proper hand hygiene, especially after touching the genital area, to prevent the spread of the bacteria to the eyes or other mucous membranes.

This instruction is especially important because eye infections from gonorrhea can lead to complications such as corneal scarring or blindness if not treated promptly.

Think of gonorrhea bacteria like dirt on your hands. If you touch your eyes with dirty hands, you can cause an infection. Washing your hands thoroughly helps keep the bacteria from spreading.

Nurse Emily should educate Mr. Carter about both personal hygiene and the importance of treating all sexual partners to prevent reinfection and further complications. Other key points include completing the full course of treatment and using condoms to prevent future infections.

• Hand hygiene: Reinforce the importance of thorough hand washing after contact with the genital area to prevent the spread of the bacteria to other areas of the body.
• Partner treatment: Encourage Mr. Carter to inform all sexual partners and ensure they receive treatment to prevent reinfection and transmission to others.
• Abstinence or condom use: Advise abstaining from sexual activity until treatment is completed or using condoms to prevent further transmission of the infection.

✘Incorrect answer options:

"Refrain from sexual activity until you've finished the full course of treatment, which lasts 14 to 21 days." This statement is incorrect because gonorrhea treatment does not require such a long duration. Gonorrhea is typically treated with a single dose of an antibiotic, such as ceftriaxone, or a short course of antibiotics. Sexual activity should be avoided for 7 days after completing treatment, not 14 to 21 days.

"If you have intercourse before completing treatment, inform your partners and advise them to wash well afterward." This is incorrect and unsafe advice. Simply washing after intercourse will not prevent the spread of gonorrhea. Patients should abstain from sexual activity until the infection is fully treated, and all partners should be informed and treated to prevent reinfection.

"Without treatment, you could develop meningitis and significant damage to your central nervous system." While gonorrhea can lead to serious complications such as pelvic inflammatory disease (PID), infertility, and disseminated gonococcal infection (DGI) (which can affect joints, heart, and skin), it is less commonly associated with meningitis. The complications of untreated gonorrhea are more likely to involve the reproductive and musculoskeletal systems.

EXPLANATION

✔Correct answer:

Isolate the patient’s bed linens until the infection is resolved. Scabies is a highly contagious skin condition caused by the Sarcoptes scabiei mite, which spreads primarily through close physical contact and contaminated clothing or linens. To prevent transmission, it is essential to isolate and properly manage the patient's bed linens and clothing until the infection is fully treated. The mites can survive for a short time on fabrics, so all items that have come into contact with the patient (linens, towels, clothing) should be laundered in hot water and dried on high heat or sealed in plastic bags for at least 72 hours. This step helps eliminate any mites or eggs that may still be present on the fabrics.

Additionally, Nurse Kelly should use contact precautions when caring for the patient, which includes wearing gloves and gowns, and ensure that proper hand hygiene is performed before and after patient contact. This helps to prevent the spread of mites to other patients or staff.

Think of the mites like little bugs that can hide in clothing and bedding. By isolating and washing the linens, you’re removing their hiding spots and stopping them from spreading to others.

Along with isolating the linens, Nurse Kelly should ensure that the patient receives appropriate treatment, typically with a topical scabicide, and that any close contacts (including staff) are assessed and treated as needed to prevent further transmission.

• Use contact precautions: Ensure gloves, gowns, and other protective equipment are used when caring for the patient to prevent the spread of mites.
• Launder linens and clothing: Wash all bedding, clothing, and towels used by the patient in hot water and dry them on high heat to kill mites and eggs.
• Monitor for signs of spread: Assess staff and other patients for any symptoms of scabies, such as itching or rash, to contain potential outbreaks.

✘Incorrect answer options:

Wash hands, apply a pediculicide to the scalp, and remove visible mites. Scabies is caused by mites that burrow into the skin, not by lice (which affect the scalp). Pediculicides are used to treat lice infestations, not scabies. The appropriate treatment for scabies is a scabicide applied to the entire body from the neck down, not just the scalp.

Inform the day surgery unit nurse about a possible scabies outbreak. While communication between units is important, notifying the day surgery unit does not directly prevent the spread of infection within the current unit. The priority is managing infection control in the immediate environment by isolating linens and using contact precautions.

Implement appropriate enteric precautions. Enteric precautions are used for gastrointestinal infections that spread through fecal-oral transmission, such as C. difficile. Scabies requires contact precautions, not enteric precautions, since it spreads through skin contact and contaminated clothing or linens.

EXPLANATION

✔Correct answer:

Related to the absorption of the corticosteroid through the skin. The application of potent topical corticosteroids under occlusive dressings significantly increases the risk of systemic absorption of the medication. When corticosteroids are absorbed in large amounts through the skin, particularly under occlusion, there is an increased risk of complications such as skin atrophy, suppression of the hypothalamic-pituitary-adrenal (HPA) axis, and other systemic effects, such as hyperglycemia or Cushing's syndrome. Therefore, formulating the nursing diagnosis as "Risk for injury related to the absorption of the corticosteroid through the skin" directly addresses the potential complications from enhanced absorption.

Occlusive dressings trap moisture and increase the penetration of the corticosteroid through the skin. While this can enhance the medication's efficacy for treating conditions like atopic dermatitis, it also raises the risk of systemic side effects, especially when potent corticosteroids are used.

Think of your skin as a sponge. When a liquid (like the medication) is covered and trapped (occlusion), the sponge absorbs more of the liquid. Similarly, when an occlusive dressing is applied over a corticosteroid, the skin absorbs more of the medication, increasing the chance for side effects.

To manage the risks associated with corticosteroid use under occlusion, Nurse Maria should implement the following interventions:

• Monitor for systemic effects: Regularly assess for signs of systemic corticosteroid absorption, such as weight gain, increased blood sugar levels, or changes in skin texture (e.g., thinning).
• Educate the patient: Teach the patient about the correct application of topical corticosteroids, the risks of using occlusive dressings, and the importance of following the prescribed duration and amount.
• Limit occlusion duration: Ensure that occlusive dressings are not used for prolonged periods without healthcare provider supervision, and alternate dressings if needed.

✘Incorrect answer options:

Related to possible drug interactions between the topical corticosteroid and other medications. This is incorrect because topical corticosteroids are generally localized treatments and have fewer systemic drug interactions compared to oral or systemic corticosteroids. The main concern is increased absorption through the skin, not drug interactions.

Related to the vasodilatory effects of the topical corticosteroid. Topical corticosteroids primarily have vasoconstrictive properties, which reduce inflammation and redness by constricting blood vessels. Vasodilation is not a typical effect associated with corticosteroids and would not be an appropriate concern for this nursing diagnosis.

Related to the application of the corticosteroid on the face, neck, and areas where skin folds. While the face, neck, and skin folds are areas more prone to side effects like thinning or discoloration, this answer is too narrow and does not fully address the broader concern of systemic absorption when corticosteroids are used with occlusive dressings. Skin folds and delicate areas do increase the risk of local side effects, but systemic absorption is the primary concern here.

EXPLANATION

✔Correct answer:

Administering systemic antibiotics as ordered. For severe impetigo, especially when the infection covers large areas or there are multiple lesions, the standard treatment includes systemic antibiotics to effectively combat the Staphylococcus aureus or Streptococcus pyogenes bacteria causing the infection. Topical treatments may be sufficient for mild cases, but in more severe cases like Mr. Wallace's, systemic antibiotics (oral or intravenous) are typically prescribed to eliminate the infection and prevent further complications, such as cellulitis or post-streptococcal glomerulonephritis.

Systemic antibiotics help ensure that the infection is addressed comprehensively, targeting the bacterial infection both locally and systemically, thus preventing the spread of infection to other parts of the body or to other people.

Think of the infection like a weed growing in your garden. While you can treat small patches with a localized spray (topical antibiotics), a severe infestation requires a more powerful solution that targets the roots throughout the garden (systemic antibiotics).

Nurse Jenna should ensure that Mr. Wallace takes his systemic antibiotics as prescribed and completes the full course of treatment. Monitoring for any signs of allergic reactions or adverse effects from the antibiotics is also important. In addition, she should educate the patient on hygiene practices to prevent the spread of the infection.

• Administer antibiotics as ordered: Ensure Mr. Wallace receives systemic antibiotics according to the prescribed dosage and schedule.
• Monitor for side effects: Watch for potential adverse effects, such as gastrointestinal upset or allergic reactions, and report any significant findings to the healthcare provider.
• Promote hygiene and infection control: Teach Mr. Wallace proper handwashing and other hygiene measures to prevent the spread of impetigo to other areas of his body or to others around him.

✘Incorrect answer options:

Putting mitts on the patient’s hands. While mitts might prevent scratching and reduce the risk of spreading the infection, this is not the primary intervention for treating severe impetigo. The focus should be on treating the underlying bacterial infection with antibiotics.

Applying topical antibiotics as directed. Topical antibiotics are effective for mild to moderate cases of impetigo, but systemic antibiotics are typically required for severe cases, as in Mr. Wallace's situation. Systemic antibiotics ensure that the infection is treated more comprehensively.

Continuing antibiotic treatment for a 21-day course as prescribed. A typical course of antibiotics for impetigo lasts 7 to 10 days, not 21 days. A 21-day course would be excessive for impetigo and is not the standard duration of treatment for this condition.

EXPLANATION

✔Correct answer:

Migratory. The formation of a scab is a hallmark sign of the migratory phase of wound healing. During this phase, the blood clot formed in the inflammatory phase dries out and forms a scab, which protects the wound as epithelial cells migrate across the wound bed beneath the scab. This phase also involves the formation of granulation tissue, which helps to repair the wound and provide a foundation for new tissue development. Fibroblasts begin producing collagen, and new blood vessels start to form to nourish the healing tissues.

Think of the scab like a natural "bandage" that covers the wound. Underneath, workers (cells) are busy repairing the structure (skin) and laying the foundation (new tissue) to complete the healing process.

Nurse Laura should ensure proper wound care during this phase to protect the scab and promote healing. It’s essential to monitor for signs of infection and to educate the patient on avoiding the removal of the scab, which could disrupt the healing process.

• Keep the wound clean: Gently clean the area to prevent infection while protecting the scab and underlying healing tissue.
• Moist wound healing: Depending on the wound, applying a moist dressing may be beneficial to support healing and prevent the scab from becoming too dry or cracking.
• Monitor for infection: Look for signs of infection such as increased redness, swelling, or pus under the scab.

✘Incorrect answer options:

Inflammatory phase occurs immediately after the injury and involves hemostasis (blood clotting) and the release of inflammatory mediators. While a clot forms during this phase, the scab forms later, during the migratory phase, as the clot dries.

Proliferative phase follows the migratory phase and is characterized by the production of new tissue, collagen, and blood vessels. While it involves tissue growth and strengthening, the scab formation occurs earlier in the migratory phase.

Maturation phase is the final stage of wound healing, during which the wound contracts and the newly formed tissue strengthens and remodels. By this phase, the scab would already have fallen off, leaving behind healed tissue that continues to mature.

EXPLANATION

✔Correct answer:

Cervical cancer. Genital herpes simplex virus (HSV-2) increases the risk of developing cervical cancer, although the primary cause of cervical cancer is the human papillomavirus (HPV), particularly high-risk strains like HPV-16 and HPV-18. Herpes infections can cause inflammation and damage to the cervical tissue, which, in combination with the presence of HPV, can further increase the risk of cellular changes that lead to cervical cancer. Therefore, patients with genital herpes should be regularly screened for HPV and undergo routine Pap smears to monitor for precancerous changes.

While HSV itself does not directly cause cervical cancer, having genital herpes can weaken the immune response and make the cervix more susceptible to HPV infection, which is why there is an associated risk.

Think of the cervix as a garden. If the soil (tissue) is damaged (by herpes), it becomes easier for weeds (HPV-related changes) to take root and grow, which can lead to cancer if not caught early.

Nurse Amanda should emphasize the importance of routine cervical cancer screening for Ms. Davis and provide education on preventing HSV-2 recurrences, including antiviral therapy and safe sexual practices.

• Promote routine screening: Encourage regular Pap smears and HPV testing to detect early signs of cervical dysplasia or cancer.
• Educate on reducing recurrences: Discuss antiviral medications (e.g., acyclovir, valacyclovir) to reduce the frequency of genital herpes outbreaks.
• Safe sex practices: Advise Ms. Davis to use condoms consistently and notify sexual partners to prevent the transmission of HSV-2 and other sexually transmitted infections (STIs).

✘Incorrect answer options:

Ovarian cancer. There is no established link between genital herpes and ovarian cancer. Ovarian cancer has different risk factors, including family history, genetic mutations (such as BRCA1 and BRCA2), and age.

Uterine cancer. Uterine cancer, also known as endometrial cancer, is primarily associated with hormone imbalances (e.g., excess estrogen) and is not linked to genital herpes infections.

Vaginal cancer. While vaginal cancer can be associated with HPV, it is not specifically linked to genital herpes simplex. Cervical cancer remains the most relevant concern when discussing genital herpes and cancer risk.

EXPLANATION

✔Correct answer:

Applying direct pressure to the wound. The first intervention for managing external bleeding is to apply direct pressure to the wound. This is the most effective and immediate way to control bleeding by compressing blood vessels at the site of injury, reducing blood flow and allowing clot formation. Direct pressure should be applied using a sterile dressing or clean cloth, and firm, continuous pressure should be maintained until the bleeding stops or emergency treatment is available.

Applying direct pressure minimizes blood loss and is typically the initial step in first aid for external bleeding, regardless of the severity. Other methods, like elevation or using a tourniquet, can be considered if direct pressure alone is insufficient, but direct pressure is always the first line of action.

Think of a garden hose with water flowing out (bleeding). Placing your thumb over the opening (direct pressure) slows or stops the water flow, just like applying pressure to a wound slows the bleeding.

Nurse Jake should assess the severity of the bleeding, apply direct pressure immediately, and continue to monitor Mr. Reynolds for signs of shock or worsening bleeding. If direct pressure is ineffective and the bleeding is severe, further measures, such as using a tourniquet, may be necessary.

• Apply direct pressure: Place a sterile dressing or clean cloth directly over the wound and apply firm pressure with both hands until bleeding stops or emergency care is provided.
• Monitor for shock: Watch for signs of hypovolemic shock, including pale, cool, or clammy skin, rapid pulse, and low blood pressure.
• Use additional techniques if needed: If direct pressure fails to control the bleeding, consider using pressure points or a tourniquet as appropriate, but these should be secondary measures.

✘Incorrect answer options:

Elevating the affected extremity. While elevation can help reduce blood flow to the affected area, it is not the first intervention. Applying direct pressure is the immediate priority. Elevation can be used as a supportive measure after direct pressure has been applied.

Using pressure point control. Pressure point control involves compressing a major artery to slow bleeding, but this is not the first step in managing external bleeding. It may be used if direct pressure is not effective, but direct pressure is simpler and more effective for most wounds.

Using a tourniquet. A tourniquet is used as a last resort when bleeding is severe and cannot be controlled by direct pressure. Improper use of a tourniquet can cause tissue damage, so it is reserved for life-threatening situations when other methods have failed.

EXPLANATION

✔Correct answer:

Ensure the client stays well hydrated. Proper hydration is essential for maintaining healthy skin integrity. Adequate water intake helps keep the skin hydrated, improves its elasticity, and promotes overall cellular function. Hydrated skin is more resilient to damage, reduces the risk of dryness and cracking, and is better able to heal from minor injuries or irritations. Dehydrated skin, on the other hand, becomes dry, flaky, and prone to breakdown, which can lead to infections and other complications.

Think of skin like a sponge. When it's well-hydrated, the sponge stays soft and flexible. If the sponge dries out, it becomes brittle and can crack. Keeping the skin "hydrated" helps it stay soft and prevents it from becoming damaged.

Nurse Jenna should encourage the patient to maintain good hydration, both by drinking water and by supporting skin hydration through proper skincare practices.

• Encourage Adequate Fluid Intake: Advise the patient to drink plenty of water daily, which helps maintain skin hydration and function.
• Use Moisturizers: Recommend applying moisturizers to prevent dryness, especially after bathing or in dry weather conditions.
• Maintain a Balanced Diet: Ensure the patient consumes a well-balanced diet, including nutrients like vitamins A and C, which support skin health.

✘Incorrect answer options:

Refrain from using mild soap when bathing the client. This is incorrect because mild soap is actually recommended for skin care. It helps cleanse the skin without stripping it of its natural oils, which are necessary for maintaining moisture and integrity. Harsh soaps, on the other hand, can irritate the skin and cause dryness.

Remove adhesive tape from the skin rapidly. This is incorrect because rapidly removing adhesive tape can cause skin tears, especially in patients with fragile skin, such as the elderly. The proper technique is to remove adhesive tape slowly and carefully, while supporting the skin to prevent injury.

Suggest wearing tight-fitting clothes in warm weather. This is incorrect because tight-fitting clothes can cause skin irritation, friction, and decreased air circulation, which can lead to conditions like heat rash or skin breakdown. It is better to recommend loose, breathable clothing, especially in warm weather, to promote skin health.

EXPLANATION

✔Correct answer:

Irritation of opposing skin surfaces caused by friction. Intertrigo is a term used to describe the inflammation and irritation that occurs when opposing skin surfaces, such as in skin folds, rub against each other. This condition is often exacerbated by moisture, heat, and friction, which can lead to maceration, redness, and sometimes secondary infections, particularly in areas like the underarms, groin, under the breasts, or between the abdominal folds.

Intertrigo is common in individuals who are overweight, have diabetes, or those living in warm, humid environments. It can be complicated by fungal or bacterial infections, particularly Candida species, which thrive in moist areas. Managing intertrigo typically involves keeping the area dry, reducing friction, and treating any secondary infections if present.

Imagine two surfaces of soft material constantly rubbing together when damp. Over time, the friction causes the material to wear down and become irritated. In your body, skin folds rubbing against each other can result in this same type of irritation, leading to intertrigo.

Nurse Jenny should provide the patient with education on how to manage and prevent intertrigo, such as keeping the area dry and clean, applying barrier creams, and using antifungal or antibacterial treatments if secondary infections are present.

• Keep skin dry: Encourage the patient to use absorbent powders or cotton fabrics to reduce moisture in affected areas.
• Reduce friction: Suggest wearing loose-fitting clothing and using protective barrier creams in areas prone to friction.
• Treat infections if present: If fungal or bacterial infections are suspected, topical antifungals or antibiotics may be prescribed.

✘Incorrect answer options:

Spontaneously occurring wheals. This describes urticaria (hives), which is a skin condition characterized by the sudden formation of itchy, raised welts on the skin. Urticaria is an allergic response, not related to friction between skin surfaces.

A fungus that enters the skin’s surface, causing infection. This refers to tinea infections, such as athlete’s foot or ringworm, which are caused by dermatophytes (fungi). While intertrigo can become infected by fungi, the primary condition is irritation from skin friction, not a fungal infection itself.

Inflammation of a hair follicle. This describes folliculitis, a condition where hair follicles become inflamed due to infection, friction, or irritation. Intertrigo, on the other hand, occurs between skin folds and is not related to hair follicles.

EXPLANATION

✔Correct answer:

Ototoxicity. Ototoxicity is the most significant and well-known adverse effect associated with gentamicin sulfate (Garamycin), an aminoglycoside antibiotic used to treat severe infections caused by gram-negative bacteria, such as staphylococcal infections. Gentamicin has the potential to cause both hearing loss (cochlear damage) and balance disturbances (vestibular damage), making it crucial for Nurse Ellen to monitor the patient for signs of ototoxicity, such as tinnitus (ringing in the ears), dizziness, and difficulty with balance or hearing.

Ototoxicity is often irreversible, so early detection is critical to preventing permanent damage. Monitoring peak and trough levels of gentamicin helps prevent toxicity by ensuring that drug concentrations stay within a therapeutic range. Additionally, patients at higher risk, such as the elderly or those with pre-existing kidney conditions, need careful monitoring since gentamicin is cleared by the kidneys, and renal impairment increases the risk of ototoxicity.

Imagine your ears like a finely tuned radio. When the volume is too high for too long (as with high doses of gentamicin), the speakers (your ears) start to break down, distorting the sound and making it hard to hear clearly (hearing loss). If the radio wires are damaged (balance system), you might also struggle to tune in to a clear station (maintain balance), causing dizziness or disorientation. That’s why gentamicin must be carefully monitored, so the "volume" stays at the right level to prevent permanent damage.

To mitigate the risk of ototoxicity, Nurse Ellen should implement the following interventions:

• Monitor for early signs of ototoxicity: Assess for tinnitus, hearing loss, vertigo, or balance issues. If these symptoms occur, the healthcare provider should be notified immediately.
• Check peak and trough levels: Regularly monitor gentamicin serum levels to ensure they remain within the therapeutic range. Trough levels are especially important to avoid drug accumulation that can lead to toxicity.
• Monitor renal function: Assess serum creatinine and blood urea nitrogen (BUN) levels regularly, as nephrotoxicity can exacerbate the risk of ototoxicity.
• Avoid concurrent ototoxic drugs: If possible, avoid combining gentamicin with other ototoxic medications, such as loop diuretics (e.g., furosemide), which could amplify the risk of hearing damage.

✘Incorrect answer options:

Aplastic anemia is a rare but serious side effect associated with certain antibiotics, such as chloramphenicol, but it is not commonly associated with gentamicin. Gentamicin primarily causes nephrotoxicity and ototoxicity rather than hematologic complications like aplastic anemia.

Cardiac arrhythmias are not a primary adverse effect of gentamicin. While electrolyte imbalances from renal damage could contribute to arrhythmias, gentamicin is not typically linked to direct cardiac toxicity.

Seizures can be associated with neurotoxicity from other drugs, especially in cases of high doses or renal impairment, but they are not a common adverse effect of gentamicin. Neurotoxicity, including seizures, would be more commonly associated with antibiotics like penicillin or certain cephalosporins.

EXPLANATION

✔Correct answer:

Using knee splints to maintain leg extension. In burn patients, contractures are a common complication during the healing process, particularly in areas where there is a natural tendency for the body to flex, such as the legs. Contractures occur when the skin and underlying tissues tighten, which can limit mobility and joint function. To prevent contractures in the legs, it is essential to maintain joint extension and prevent prolonged periods of flexion.

Using knee splints is a key intervention in this case because they help keep the legs in an extended position, preventing the natural tendency for the knees to contract during healing. Splints can support proper alignment and range of motion, reducing the risk of contracture formation.

Imagine a rubber band that, when left in one position for too long, shrinks and becomes hard to stretch. If you keep the rubber band extended, it stays flexible and can move freely. Knee splints work similarly by keeping the leg in an extended position to prevent tightness and contraction.

Nursing interventions focus on maintaining mobility and promoting joint function, which is crucial in preventing permanent contractures and supporting the patient's rehabilitation process.

• Use of Splints: Apply knee splints or other devices to maintain proper joint alignment and prevent flexion contractures.
• Positioning: Ensure the patient's legs are regularly positioned in extension, avoiding prolonged periods of flexion.
• Range of Motion (ROM): Assist the patient with passive and active range-of-motion exercises to maintain flexibility and joint mobility.
• Education: Educate the patient and family on the importance of these interventions for long-term functional outcomes.

✘Incorrect answer options:

Raising the foot of the bed. While elevating the legs can reduce edema and improve circulation in some patients, this intervention does not specifically address the prevention of contractures. Contracture prevention requires maintaining proper joint alignment and extension.

Overextending the patient's palms. This intervention is not relevant to the prevention of contractures in the legs. Overextension of the palms may be appropriate in cases where there is a risk of hand contractures, but it does not apply to the lower extremities in this case.

Assisting with shoulder range-of-motion exercises. Although range-of-motion exercises are important for preventing contractures, shoulder exercises do not directly address contracture prevention in the legs. The focus here should be on leg-specific interventions, such as using knee splints and performing leg ROM exercises.

EXPLANATION

✔Correct answer:

Managing his pain effectively. For a patient like Mr. Brooks presenting with a severe solar (sun) burn, pain management is the immediate priority. Solar burns, especially those affecting large areas like the chest, back, face, and arms, can cause significant discomfort and may even impair the patient's ability to rest, eat, or perform daily activities. Sunburn pain is typically intense due to inflammation, and managing this pain is essential to improve the patient’s comfort and ability to recover. Effective pain management can include nonsteroidal anti-inflammatory drugs (NSAIDs) and topical treatments to soothe the skin and reduce discomfort.

While preventing infection, ensuring fluid balance, and addressing body image concerns are important aspects of care, they are not the primary focus in the initial stages of treatment for severe sunburn. Sunburns do not typically result in infection unless the skin becomes blistered and breaks, so infection prevention is not an immediate concern in this case unless blisters rupture.

Think of a bad sunburn like touching a hot stove—your first response is to manage the pain. Once the pain is controlled, you can then focus on protecting the area and healing.

Nurse Jenna should assess the level of pain and provide appropriate analgesics, along with topical soothing treatments like aloe vera or cool compresses to help relieve discomfort. She should also educate Mr. Brooks about the importance of preventing further sunburn and protecting his skin in the future.

• Pain management: Administer NSAIDs or analgesics as needed to reduce pain and inflammation, and apply topical treatments to soothe the affected skin.
• Skin protection: Encourage the patient to stay out of the sun while healing and to use sunscreen and protective clothing in the future to prevent further burns.
• Hydration: Encourage adequate fluid intake to help the body recover from the burn and prevent dehydration, as severe sunburn can lead to fluid loss.

✘Incorrect answer options:

Ensuring proper fluid resuscitation. While fluid resuscitation is critical for patients with extensive burns that lead to severe dehydration, this is more applicable to cases involving second- or third-degree burns, particularly those affecting a large percentage of the body. Severe sunburns (first-degree burns) typically do not require fluid resuscitation unless there are significant blisters or systemic dehydration.

Preventing infection. Infection prevention becomes more of a priority if blisters form and rupture, but in the early stages of a sunburn (first-degree), the skin is intact, and infection is not an immediate concern.

Addressing concerns about body image. Although body image concerns are valid, especially if the sunburn is severe and affects visible areas like the face, they are not the primary concern during the acute phase of care. Managing pain and ensuring healing takes precedence in the early stages of treatment.

EXPLANATION

✔Correct answer:

36% The Rule of Nines is a widely used tool for quickly estimating the total body surface area (TBSA) affected by burns in adults. It divides the body into sections, each corresponding to a percentage of TBSA, making it easier for healthcare providers to assess the extent of burns and plan treatment.

In this case, Nurse Sarah is assessing burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, these areas correspond to the following percentages:

• Left arm (entire arm): Each arm accounts for 9% of TBSA (4.5% anterior and 4.5% posterior). Since it says "left arm" without specifying anterior or posterior, we assume the entire arm is affected, contributing 9%.
• Left anterior leg: Each leg represents 18% of TBSA (9% for anterior and 9% for posterior). The anterior portion of the left leg contributes 9%.
• Anterior trunk: The anterior trunk accounts for 18% of TBSA.

Adding these values together:

• Left arm: 9%
• Left anterior leg: 9%
• Anterior trunk: 18%

The total estimated TBSA burned is 9% + 9% + 18% = 36%.

Imagine the body as a pie chart where each section of the body represents a slice. The arms, legs, and trunk each take up specific percentages of the "pie" (total body surface). By adding the percentages of the affected areas, you can quickly estimate how much of the "pie" has been burned.

Accurate estimation of the TBSA affected by burns is crucial for determining the necessary interventions, including fluid resuscitation and wound management. Burns that cover more than 20% TBSA are considered major and require careful monitoring and aggressive treatment.

• Fluid Resuscitation: Burns involving more than 20% TBSA typically require large volumes of intravenous fluids. The Parkland formula is commonly used to guide fluid therapy and prevent burn shock.
• Infection Prevention: Burn wounds covering a large area increase the risk of infection due to compromised skin integrity. Proper wound care and infection control measures are critical.
• Pain Management: Large burns are usually associated with significant pain, requiring careful pain management strategies, including both pharmacological and non-pharmacological interventions.
• Emotional and Psychological Support: Patients with extensive burns may experience emotional trauma due to the severity of the injury and the potential for long-term physical changes, requiring psychological support and counseling.

✘Incorrect answer options:

18% This estimate would apply if only the anterior trunk (18%) was affected. However, in this case, the left arm and left anterior leg are also involved, so this option underestimates the TBSA.

27% This option includes the anterior trunk (18%) and either the left arm (9%) or the left anterior leg (9%), but it does not account for all the affected areas (arm, leg, and trunk).

30% This is an overestimate of the TBSA affected. It doesn't match the Rule of Nines calculation based on the specific areas mentioned (left arm, left anterior leg, anterior trunk), which total 36%.

EXPLANATION

✔Correct answer:

A urine output consistently above 100 ml/hour. Urine output is one of the most reliable indicators of effective fluid resuscitation, particularly in patients with significant burns. In burn management, maintaining adequate renal perfusion and ensuring that the kidneys are filtering and excreting fluids appropriately is critical. A urine output of 30–50 ml/hour is considered adequate for most patients receiving fluid resuscitation, but in burn patients, the target is typically higher. Urine output above 100 ml/hour indicates that the patient's kidneys are well-perfused, and fluid resuscitation is achieving its goal of maintaining effective circulatory volume and preventing complications like hypovolemic shock.

In burn patients, the massive fluid loss that occurs due to the destruction of the skin barrier, fluid shift into the interstitial spaces, and increased capillary permeability makes fluid resuscitation vital in the first 24 to 48 hours post-injury. Monitoring urine output is a simple yet effective way to gauge whether the fluid resuscitation is adequate.

Think of the kidneys like a coffee filter. If enough water (fluids) is going through, you’ll get a steady drip of coffee (urine output). If not enough water passes through, it means the filter isn’t working well and more fluid is needed to get the right flow.

Nurse Karen should continuously monitor the patient’s urine output to assess the effectiveness of fluid therapy. If urine output decreases, this could be an early sign of inadequate perfusion or progressing shock, and adjustments to fluid administration may be required.

• Monitor fluid balance: Regularly assess urine output and other fluid balance markers (e.g., central venous pressure) to ensure adequate resuscitation.
• Monitor for signs of fluid overload: Watch for signs such as pulmonary edema or excessive weight gain, as these may indicate that fluid administration is excessive.
• Adjust fluids as needed: Follow the fluid resuscitation protocol closely (e.g., Parkland formula) and adjust as needed based on urine output and other hemodynamic parameters.

✘Incorrect answer options:

A weight gain of 4 lb (2 kg) in 24 hours. While some weight gain is expected due to fluid administration during resuscitation, a rapid weight gain of 4 lb (2 kg) within 24 hours could indicate fluid overload, which is not necessarily a sign of effective fluid resuscitation. Monitoring for signs of overhydration is crucial to avoid complications like pulmonary edema.

Body temperature readings consistently within normal limits. Normal body temperature is important, but it does not directly reflect the effectiveness of fluid resuscitation. Burn patients may experience temperature dysregulation due to skin damage, and maintaining normothermia is essential, but it’s not the primary indicator of fluid resuscitation success.

An electrocardiogram (ECG) showing no arrhythmias. Absence of arrhythmias is a good sign, especially in patients with potential electrolyte imbalances, but it does not provide a direct indication of whether fluid resuscitation is adequate. Fluid therapy is aimed at restoring circulating volume and perfusion, not specifically at preventing arrhythmias.