Question 1 of 6
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Which nursing intervention may help a patient who is losing sleep related to itching the skin?
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- Suggesting ways to use distraction to decrease the focus on itchingOne nursing intervention that would assist a patient who is losing sleep related to skin itching is suggesting ways to use distraction to decrease the focus on itching.
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- Creating a new bedtime ritual for the patient to optimize sleepIt is most beneficial to the patient to follow their usual bedtime rituals that help induce sleep.
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- Encouraging the patient to gently scratch the lesions as needed for reliefThe patient should be encouraged not to scratch lesions because it makes itching worse.
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- Instructing the patient to take warm or hot baths or showers to reduce itchingCool or tepid baths and showers will decrease itching.
Question 2 of 6
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Which season of the year is associated with increased itchy skin?
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- SummerSummer is not associated with itchy skin. Skin gets itchy in cold temperatures when it becomes dry. In the summer, sweating helps keep the skin moist.
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- SpringSpring has mild temperatures, not hot or cold. Because it is not cold in the spring, the skin does not dry out and itch.
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- WinterItching and pain are the most common skin complaints. If the patient has recently been exposed to a severe cold, the skin may be drier than usual, and the patient may complain of severe itching (winter itch).
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- FallFall has mild temperatures, not hot or cold. Because it is not usually excessively cold in the fall, the skin does not dry out and itch.
Question 3 of 6
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For which reason would the nurse lightly palpate a patient’s skin anywhere on the body? Select all that apply. One, some, or all responses may be correct.
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- Temperature changesLight palpation of the skin is used to detect areas of increased warmth. Palpate with the back of the hand for temperature changes because it is more sensitive to temperature.
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- PainLight palpation of the skin is used to detect pain. If palpation elicits an unpleasant response from the patient, pain is present.
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- TextureThe skin should be lightly palpated to detect changes in texture and surface elevations. This is how the skin feels (e.g., rough, smooth).
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- TendernessLight palpation of the skin is used to detect tenderness. If palpation elicits an unpleasant response from the patient, tenderness is present.
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- Pulse rateTo determine the pulse rate, the skin must be firmly palpated over the radial artery. The pulse rate cannot be lightly palpated anywhere on a patient’s skin.
Question 4 of 6
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Which simple skin observation is used to determine a diagnosis of dehydration in an older adult?
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- EcchymosisEcchymosis is bleeding under the skin (bruising) a purple discoloration. This does not reflect dehydration.
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- TentingSkin turgor is assessed by lifting a fold of skin on the forearm, chest, or abdomen between two fingers and seeing how fast it falls back into place. Skin that takes longer than 1 to 2 seconds to return to place and stays up like a tent is called tenting and indicates dehydration.
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- DiscolorationDiscoloration occurs because of bruising, rashes, and so forth. This is a significant finding but does not indicate dehydration.
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- PittingPitting (dimpling) is found with edema and is an indicator of the amount of fluid that a person is retaining in their locally or systemically. Pitting is not an indicator of dehydration.
Question 5 of 6
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Which task would be inappropriate for the nurse to delegate to unlicensed assistive personnel?
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- Completing the total skin assessmentThe total skin assessment cannot be delegated by the nurse to unlicensed assistive personnel. This is the nurse’s responsibility.
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- Reporting new bruises on patientsUnlicensed personnel are at the bedside more and find bruises. They are to report these findings to the nurse. Unlicensed assistive personnel are generally assisting with hygiene, and the nurse should give specific Instructions to report reddening, bruising, breaks in the skin, or new lesions.
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- Reporting discoloration of a patient’s skinUnlicensed personnel are at the bedside more and find discoloration. They are to report these findings to the nurse. Unlicensed assistive personnel are generally assisting with hygiene, and the nurse should give specific Instructions to report reddening, bruising, breaks in the skin, or new lesions.
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- Reporting a break in a patient’s skin integrityUnlicensed personnel are at the bedside more and find breaks in skin integrity. They are to report these findings to the nurse. Unlicensed assistive personnel are generally assisting with hygiene, and the nurse should give specific Instructions to report reddening, bruising, breaks in the skin, or new lesions.