A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan(select the one that does not apply)?

Correct Answer: C

Rationale: The correct answer is C. Adding oil to bath water can exacerbate contact dermatitis by further irritating the skin. Oil can create a barrier that traps irritants and moisture, worsening symptoms. The other options are appropriate for managing pruritus in contact dermatitis. A: Cool, wet cloths or compresses can provide relief by soothing and reducing inflammation. B: Cool or tepid baths help to soothe the skin and reduce itching. D: Rubbing dry with a towel after bathing helps prevent skin maceration and further irritation. Adding oil to bath water is contra-indicated in contact dermatitis management.

Correct Answer: A

Rationale: The correct answer is A because pulling a stroke client up in bed can create friction and shear forces on the skin, leading to pressure ulcer formation. This action puts pressure on vulnerable areas of the skin, especially if the client is immobile or has limited mobility. Turning a client from side to side every 2 hours (B) is actually a preventive measure to reduce pressure ulcer risk by redistributing pressure. Allowing a client to slide up in a chair at mealtime (C) may not directly contribute to pressure ulcers unless prolonged pressure is exerted. Applying powder to buttocks area when diaphoresis has become a problem (D) can help reduce moisture but is not a direct cause of pressure ulcers.

Correct Answer: B

Rationale: The correct answer is B: Actinic keratosis. Actinic keratosis is considered a premalignant lesion because it is caused by prolonged sun exposure and can progress to squamous cell carcinoma if left untreated. It appears as rough, scaly patches on the skin and is commonly seen in elderly individuals with a history of sun damage. Cherry angiomas (A), solar lentigines (C), and telangiectases (D) are not considered premalignant lesions. Cherry angiomas are benign skin growths, solar lentigines are age spots caused by sun exposure, and telangiectases are dilated blood vessels.

Correct Answer: D

Rationale: A sacral injury with exposed bone is 'Stage 4' , per Potter's *Essentials* and NPUAP. Full-thickness loss e.g., bone visible 2 cm deep may include tunneling, unlike 'Stage 1' , nonblanchable redness e.g., intact skin. 'Stage 2' is partial-thickness e.g., shallow ulcer, no bone. 'Stage 3' is full-thickness e.g., fat visible, not bone. A nurse charting e.g., Bone at sacrum' notes Stage 4's severity (e.g., 20% of sacral ulcers), needing debridement. Potter defines Stage 4 as deepest damage, distinct from Stage 3's limit at subcutaneous fat, a physiological integrity key. is the correct, advanced stage.

Correct Answer: B

Rationale: A pale pink incision 2 months post-surgery is in 'remodeling phase' , per Potter's. Collagen reorganizes e.g., scar strengthens 80% by 6 weeks unlike 'hemostasis' , initial bleeding stop e.g., minutes post-op. 'Proliferative' builds tissue e.g., days 3-21, red granulation. 'Inflammation' cleans e.g., first 3 days, swelling. A nurse assesses e.g., Faint scar' remodeling's 3-month span, per healing science, a physiological marker. Potter defines this as scar maturation, distinct from proliferative's growth, making the correct, late stage.