MS Ch. 24- Assessment of Skin, Hair,
Nails (Evolve)
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs,
and nursing assistants. Which client does the nurse plan to assign to an
experienced LPN/LVN?
Adult client who has had suturing of a facial tear that occurred when the client
fell off a bike onto a dirt road
Adult client who needs to be admitted for a grafting of a second-degree burn
on the right leg
Middle-aged adult client who needs discharge teaching before going home
after receiving steroids for Stevens-Johnson syndrome
Older adult client with stage I pressure ulcers who needs to be turned every 2
hours -Adult client who has had suturing of a facial tear that occurred when
the client fell off a bike onto a dirt road
The nurse identifies the priority problem of skin breakdown related to poor
hygiene in a long-term-care client who has areas of skin breakdown in the
skinfolds and the perineal area. Which intervention is best for the RN to
delegate to the nursing assistant?
Check the client's skin weekly for areas of redness or breakdown.
Teach the client and family about the importance of good hygiene in
skinfolds.
Evaluate the client's ability to provide skin hygiene independently.
Bathe the client, and apply a protective barrier to skinfolds and perineum. -
Bathe the client, and apply a protective barrier to skinfolds and perineum.
, A client who has had an excisional biopsy of a skin lesion in the same-day
surgery unit is ready for discharge. Which nursing activity does the nurse
assign to an LPN/LVN working with this client?
Teach the client about signs of incisional infection.
Instruct the client about how to do dressing changes.
Apply an antibiotic ointment and place a sterile dressing on the incision.
Complete the written discharge instructions for the long-term-care facility. -
Apply an antibiotic ointment and place a sterile dressing on the incision.
Which activity for a long-term-care client does the nurse plan to assign to the
LPN/LVN?
Develop a care plan for a client who has blisters caused by herpes zoster.
Administer an antihistamine to a client who is describing pruritus.
Teach a client how to self-assess for changes in skin lesions.
Perform a baseline skin assessment for a newly admitted client. -Administer
an antihistamine to a client who is describing pruritus.
The home health nurse is doing an intake assessment on a client who had a
recent shave biopsy of a basal cell carcinoma located on the client's cheek.
Which statement by the client may indicate the greatest need for client
teaching?
"Every morning, I check the biopsy site for signs of infection."
"I have been cleaning my face with soap and water."
"My appetite is improving lately."
"I have been working in my garden for several hours every day." -"I have
been working in my garden for several hours every day."
Nails (Evolve)
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs,
and nursing assistants. Which client does the nurse plan to assign to an
experienced LPN/LVN?
Adult client who has had suturing of a facial tear that occurred when the client
fell off a bike onto a dirt road
Adult client who needs to be admitted for a grafting of a second-degree burn
on the right leg
Middle-aged adult client who needs discharge teaching before going home
after receiving steroids for Stevens-Johnson syndrome
Older adult client with stage I pressure ulcers who needs to be turned every 2
hours -Adult client who has had suturing of a facial tear that occurred when
the client fell off a bike onto a dirt road
The nurse identifies the priority problem of skin breakdown related to poor
hygiene in a long-term-care client who has areas of skin breakdown in the
skinfolds and the perineal area. Which intervention is best for the RN to
delegate to the nursing assistant?
Check the client's skin weekly for areas of redness or breakdown.
Teach the client and family about the importance of good hygiene in
skinfolds.
Evaluate the client's ability to provide skin hygiene independently.
Bathe the client, and apply a protective barrier to skinfolds and perineum. -
Bathe the client, and apply a protective barrier to skinfolds and perineum.
, A client who has had an excisional biopsy of a skin lesion in the same-day
surgery unit is ready for discharge. Which nursing activity does the nurse
assign to an LPN/LVN working with this client?
Teach the client about signs of incisional infection.
Instruct the client about how to do dressing changes.
Apply an antibiotic ointment and place a sterile dressing on the incision.
Complete the written discharge instructions for the long-term-care facility. -
Apply an antibiotic ointment and place a sterile dressing on the incision.
Which activity for a long-term-care client does the nurse plan to assign to the
LPN/LVN?
Develop a care plan for a client who has blisters caused by herpes zoster.
Administer an antihistamine to a client who is describing pruritus.
Teach a client how to self-assess for changes in skin lesions.
Perform a baseline skin assessment for a newly admitted client. -Administer
an antihistamine to a client who is describing pruritus.
The home health nurse is doing an intake assessment on a client who had a
recent shave biopsy of a basal cell carcinoma located on the client's cheek.
Which statement by the client may indicate the greatest need for client
teaching?
"Every morning, I check the biopsy site for signs of infection."
"I have been cleaning my face with soap and water."
"My appetite is improving lately."
"I have been working in my garden for several hours every day." -"I have
been working in my garden for several hours every day."
