Author Question: A nurse is participating in a health fair that is being sponsored by a local seniors' center, ... (Read 51 times)

Tazate · **on:** Jul 11, 2018

A nurse is participating in a health fair that is being sponsored by a local seniors' center, discussing healthy skin and aging. Which of the following teaching points should the nurse emphasize?

A) You should limit your sun exposure to a small amount each day and keep your skin protected from direct sunlight for the remainder.
B) Many drugs can have an effect on your skin, so it's important to avoid most over-the-counter medications.
C) The health of your skin is primarily determined by your genes, so all you can do is try to maintain your overall level of health.
D) Even if you find it difficult to do, it's important to bathe once a day.

Question 2

A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which of the following should the nurse document?

A) 2-mm stage II pressure ulcer
B) Stage III pressure ulcer on great toe
C) 2-mm skin tear with red wound bed
D) Red ulcer on the great toe 2 mm in size

CharlieArnold · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

Ans: A
Current recommendations emphasize the importance of a balanced approach that encourages small amounts of sun exposure each day for adequate vitamin D synthesis, but not so much that would lead to increased skin cancer risk. Many medications affect the skin, but it would be inappropriate for the nurse to recommend that older adults refrain from all over-the-counter medications. Genetic factors influence integumentary health, but this does not mean that other risk factors are irrelevant or nonmodifiable. It is unnecessary for most older adults to bathe every day.

Answer to Question 2

Ans: A
The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging should be used to document all pressure ulcers. Wound documentation should also include size of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.