Saunders NCLEX-RN
Isotretinoin is prescribed for a client with
severe cystic acne. The nurse provides 1."I need to continue to take my vitamin
instructions to the client regarding ad- A supplements."
ministration of the medication. Which Rationale: In severe cystic acne,
phrase stated by the client indicates a isotretinoin is used to inhibit inflamma-
need for further teaching regarding this tion. Adverse effects include elevated
medication? triglyceride levels, skin dryness, eye dis-
1."I need to continue to take my vitamin comfort such as dryness and burning,
A supplements." and cheilitis (lip inflammation). Close
2."The medication may cause dryness medical follow-up is required, and dry
and burning in my eyes." skin and cheilitis can be decreased by
3."I need to use emollients and lip balms the use of emollients and lip balms. Vit-
for my dry skin and lips." amin A supplements are stopped during
4."I will need to return for a blood test to this treatment.
check my triglyceride level."
Altered body image
Psoriasis is an autoimmune dermatitis
that is expressed as silvery scales on
reddish-colored skin on areas such as
scalp, elbows, hands, and knees. Onset
In planning care for the client with pso- of the disease generally occurs before
riasis, the nurse understands that which age 40, with symptoms varying in in-
represents a priority client problem? tensity from mild to severe. Skin disor-
1.Fatigue ders, particularly when experienced by
2.Constipation young persons and particularly when vis-
3.Impaired safety ible on exposed body parts, can cause
4.Altered body image significant psychosocial distress. Altered
body image is a priority client problem
that should be considered when plan-
ning care for a client with psoriasis. The
remaining options are not priority client
problems associated with psoriasis.
1.Applying warm compresses to the af-
The nurse expects to note which pre- fected area
scription for a client with a skin infection Warm compresses may be prescribed
that extends into the dermis? to decrease the discomfort, erythema,
1.Applying warm compresses to the af- and edema associated with a skin in-
fection that is characteristic of cellulitis.
, Saunders NCLEX-RN
The nurse should also provide support-
fected area 2.Placing iced compresses ive care as prescribed to manage associ-
to the affected area every 4 hours ated symptoms such as fever or chills. Af-
3.Alternating the application of hot and ter tissue and blood are obtained for cul-
iced compresses every 2 hours ture, antibiotics are initiated. Heat lamps
4.Placing antibiotic ointment on the af- can cause more disruption to already in-
fected site followed by continuous heat flamed tissue. Iced compresses are not
lamp application prescribed because they can damage
tissue.
2.A skin infection of the dermis and un-
A client is being admitted to the hos-
derlying hypodermis
pital for treatment of acute cellulitis of
Cellulitis is an infection of the dermis
the lower left leg. During the admission
and underlying hypodermis that results
assessment, the nurse expects to note
in a deep red erythema without sharp
which finding?
borders and spreads widely throughout
1.An inflammation of the epidermis only
tissue spaces. The skin is erythema-
2.A skin infection of the dermis and un-
tous, edematous, tender, and sometimes
derlying hypodermis
nodular. Erysipelas is an acute, super-
3.An acute superficial infection of the
ficial, rapidly spreading inflammation of
dermis and lymphatics
the dermis and lymphatics. The infec-
4.An epidermal and lymphatic infection
tion is not superficial and extends deeper
caused by Staphylococcus
than the epidermis.
An outbreak of head lice infestation
has occurred at a local school. The
school nurse is providing instructions
4.Leave the lotion on for 8 to 12 hours,
to the mothers of the children attend-
and then wash the hair with nonmedicat-
ing the school regarding the application
ed shampoo.
of malathion. The nurse should tell the
Rationale: The instructions for the use of
mothers to take which action?
malathion are as follows: Sprinkle lotion
1.Apply the lotion immediately after
on dry hair and rub gently until the scalp
washing the hair.
is moistened; allow to dry naturally; af-
2.Pour the lotion onto the hair and then
ter 8 to 12 hours, wash the hair with a
rinse immediately.
nonmedicated shampoo; rinse and use
3.Allow the lotion to remain on the hair
a fine-toothed comb to remove lice; and
for 10 minutes and then rinse with water.
repeat in 7 to 9 days if needed.
4.Leave the lotion on for 8 to 12 hours,
and then wash the hair with nonmedicat-
ed shampoo.
, Saunders NCLEX-RN
1.It is caused by a tick bite.
The nurse is providing an educational
Lyme disease is a multisystem infection
session to community members regard-
that results from a bite by a tick that
ing Lyme disease. The nurse should pro-
is usually carried by several species of
vide what information regarding this dis-
deer. Persons bitten by the Ixodes ticks
ease?
are infected with the spirochete Borre-
1.It is caused by a tick bite.
lia burgdorferi. Lyme disease cannot be
2.It can be contagious by skin contact
transmitted from 1 person to another.
with an infected person.
Histoplasmosis is caused by the inhala-
3.It can be caused by the inhalation of
tion of spores from bat or bird droppings.
spores from bird droppings.
Toxoplasmosis is caused from the in-
4.It is caused by contamination from cat
halation of cysts from contaminated cat
feces or the consumption of rare or raw
feces or the consumption of rare or raw
meat.
meat.
1.Clustered skin vesicles
The nurse suspects herpes zoster (shin-
The primary lesion of herpes zoster is
gles) when which assessment finding is
a vesicle. The classic presentation is
noted?
grouped vesicles on an erythematous
1.Clustered skin vesicles
base along a dermatome. Because the
2.A generalized body rash
lesions follow nerve pathways, they do
3.Small blue-white spots with a red base
not cross the midline of the body. Options
4.A fiery red, edematous rash on the
2, 3, and 4 are incorrect descriptions of
cheeks
herpes zoster.
4."I need to be sure to take my vitamin
Isotretinoin has been prescribed for an
A supplement so that the treatment will
adolescent with a diagnosis of severe
work."
cystic acne. The nurse provides instruc-
Rationale:
tions to the adolescent regarding the
Isotretinoin is used to inhibit inflamma-
use of the medication. Which statement,
tion in the client with severe cystic acne.
if made by the adolescent, indicates a
Vitamin A supplements are stopped dur-
need for further instruction?
ing this treatment because isotretinoin is
1."I will return to the clinic for blood
a derivative of vitamin A, and taking vit-
tests."
amin A concurrently will induce additive
2."My eyes may become dry and burn as
effects. Adverse effects include elevat-
a result of the medication."
ed triglycerides, skin dryness, and eye
3."If my lips begin to burn, this is proba-
discomfort, such as dryness and burn-
bly because of the medication."
ing. Lip inflammation, called cheilitis, also
4."I need to be sure to take my vitamin
can occur.
Isotretinoin is prescribed for a client with
severe cystic acne. The nurse provides 1."I need to continue to take my vitamin
instructions to the client regarding ad- A supplements."
ministration of the medication. Which Rationale: In severe cystic acne,
phrase stated by the client indicates a isotretinoin is used to inhibit inflamma-
need for further teaching regarding this tion. Adverse effects include elevated
medication? triglyceride levels, skin dryness, eye dis-
1."I need to continue to take my vitamin comfort such as dryness and burning,
A supplements." and cheilitis (lip inflammation). Close
2."The medication may cause dryness medical follow-up is required, and dry
and burning in my eyes." skin and cheilitis can be decreased by
3."I need to use emollients and lip balms the use of emollients and lip balms. Vit-
for my dry skin and lips." amin A supplements are stopped during
4."I will need to return for a blood test to this treatment.
check my triglyceride level."
Altered body image
Psoriasis is an autoimmune dermatitis
that is expressed as silvery scales on
reddish-colored skin on areas such as
scalp, elbows, hands, and knees. Onset
In planning care for the client with pso- of the disease generally occurs before
riasis, the nurse understands that which age 40, with symptoms varying in in-
represents a priority client problem? tensity from mild to severe. Skin disor-
1.Fatigue ders, particularly when experienced by
2.Constipation young persons and particularly when vis-
3.Impaired safety ible on exposed body parts, can cause
4.Altered body image significant psychosocial distress. Altered
body image is a priority client problem
that should be considered when plan-
ning care for a client with psoriasis. The
remaining options are not priority client
problems associated with psoriasis.
1.Applying warm compresses to the af-
The nurse expects to note which pre- fected area
scription for a client with a skin infection Warm compresses may be prescribed
that extends into the dermis? to decrease the discomfort, erythema,
1.Applying warm compresses to the af- and edema associated with a skin in-
fection that is characteristic of cellulitis.
, Saunders NCLEX-RN
The nurse should also provide support-
fected area 2.Placing iced compresses ive care as prescribed to manage associ-
to the affected area every 4 hours ated symptoms such as fever or chills. Af-
3.Alternating the application of hot and ter tissue and blood are obtained for cul-
iced compresses every 2 hours ture, antibiotics are initiated. Heat lamps
4.Placing antibiotic ointment on the af- can cause more disruption to already in-
fected site followed by continuous heat flamed tissue. Iced compresses are not
lamp application prescribed because they can damage
tissue.
2.A skin infection of the dermis and un-
A client is being admitted to the hos-
derlying hypodermis
pital for treatment of acute cellulitis of
Cellulitis is an infection of the dermis
the lower left leg. During the admission
and underlying hypodermis that results
assessment, the nurse expects to note
in a deep red erythema without sharp
which finding?
borders and spreads widely throughout
1.An inflammation of the epidermis only
tissue spaces. The skin is erythema-
2.A skin infection of the dermis and un-
tous, edematous, tender, and sometimes
derlying hypodermis
nodular. Erysipelas is an acute, super-
3.An acute superficial infection of the
ficial, rapidly spreading inflammation of
dermis and lymphatics
the dermis and lymphatics. The infec-
4.An epidermal and lymphatic infection
tion is not superficial and extends deeper
caused by Staphylococcus
than the epidermis.
An outbreak of head lice infestation
has occurred at a local school. The
school nurse is providing instructions
4.Leave the lotion on for 8 to 12 hours,
to the mothers of the children attend-
and then wash the hair with nonmedicat-
ing the school regarding the application
ed shampoo.
of malathion. The nurse should tell the
Rationale: The instructions for the use of
mothers to take which action?
malathion are as follows: Sprinkle lotion
1.Apply the lotion immediately after
on dry hair and rub gently until the scalp
washing the hair.
is moistened; allow to dry naturally; af-
2.Pour the lotion onto the hair and then
ter 8 to 12 hours, wash the hair with a
rinse immediately.
nonmedicated shampoo; rinse and use
3.Allow the lotion to remain on the hair
a fine-toothed comb to remove lice; and
for 10 minutes and then rinse with water.
repeat in 7 to 9 days if needed.
4.Leave the lotion on for 8 to 12 hours,
and then wash the hair with nonmedicat-
ed shampoo.
, Saunders NCLEX-RN
1.It is caused by a tick bite.
The nurse is providing an educational
Lyme disease is a multisystem infection
session to community members regard-
that results from a bite by a tick that
ing Lyme disease. The nurse should pro-
is usually carried by several species of
vide what information regarding this dis-
deer. Persons bitten by the Ixodes ticks
ease?
are infected with the spirochete Borre-
1.It is caused by a tick bite.
lia burgdorferi. Lyme disease cannot be
2.It can be contagious by skin contact
transmitted from 1 person to another.
with an infected person.
Histoplasmosis is caused by the inhala-
3.It can be caused by the inhalation of
tion of spores from bat or bird droppings.
spores from bird droppings.
Toxoplasmosis is caused from the in-
4.It is caused by contamination from cat
halation of cysts from contaminated cat
feces or the consumption of rare or raw
feces or the consumption of rare or raw
meat.
meat.
1.Clustered skin vesicles
The nurse suspects herpes zoster (shin-
The primary lesion of herpes zoster is
gles) when which assessment finding is
a vesicle. The classic presentation is
noted?
grouped vesicles on an erythematous
1.Clustered skin vesicles
base along a dermatome. Because the
2.A generalized body rash
lesions follow nerve pathways, they do
3.Small blue-white spots with a red base
not cross the midline of the body. Options
4.A fiery red, edematous rash on the
2, 3, and 4 are incorrect descriptions of
cheeks
herpes zoster.
4."I need to be sure to take my vitamin
Isotretinoin has been prescribed for an
A supplement so that the treatment will
adolescent with a diagnosis of severe
work."
cystic acne. The nurse provides instruc-
Rationale:
tions to the adolescent regarding the
Isotretinoin is used to inhibit inflamma-
use of the medication. Which statement,
tion in the client with severe cystic acne.
if made by the adolescent, indicates a
Vitamin A supplements are stopped dur-
need for further instruction?
ing this treatment because isotretinoin is
1."I will return to the clinic for blood
a derivative of vitamin A, and taking vit-
tests."
amin A concurrently will induce additive
2."My eyes may become dry and burn as
effects. Adverse effects include elevat-
a result of the medication."
ed triglycerides, skin dryness, and eye
3."If my lips begin to burn, this is proba-
discomfort, such as dryness and burn-
bly because of the medication."
ing. Lip inflammation, called cheilitis, also
4."I need to be sure to take my vitamin
can occur.
