A patient has a blood-filled blister surrounded by tissue that is painful, mushy, and warm to the touch. How should the nurse classify this skin presentation?

Correct Answer: D

Rationale: The correct answer is D: Suspected tissue injury. This classification is appropriate because the skin presentation described does not meet the specific criteria for Stage III or IV ulcers, which involve skin breakdown and tissue damage extending into deeper layers. The term "unstageable" is used when the wound bed is obscured, usually by eschar or slough, making it impossible to determine the depth of tissue damage. In this case, the presence of a blood-filled blister and pain suggests a superficial injury without visible tissue loss, indicating a suspected tissue injury rather than a defined stage of ulcer development. This classification allows for further assessment and monitoring to determine the extent of tissue damage.

Correct Answer: B

Rationale: The correct answer is B because applying an emollient after a bath or shower helps seal in moisture and prevents evaporation of water from the hydrated epidermis, promoting hydration and maintaining skin integrity. This is crucial for managing pruritus. Summary: A: While emollients can help reduce skin irritation, the main purpose of applying it after a bath is to prevent water loss. C: Emollients do not enhance skin absorption of medication. D: Cooling the skin is not the primary reason for applying emollients after a bath.

Correct Answer: A

Rationale: The correct answer is A: Partial-thickness skin loss of the dermis. This aligns with the definition of a stage II pressure ulcer, which involves partial-thickness skin loss involving the epidermis and/or dermis. This stage typically presents as a shallow open ulcer with a red-pink wound bed. Choice B (Full-thickness skin loss) is incorrect as it corresponds to a stage III pressure ulcer where there is full-thickness tissue loss. Choice C (Blistering without skin loss) is incorrect as it describes a stage II pressure injury, not a pressure ulcer. Choice D (Intact skin with redness) is incorrect as it signifies a stage I pressure ulcer, where there is non-blanchable erythema of intact skin. Therefore, the nurse would expect to see partial-thickness skin loss of the dermis in the sacral area of the client with a stage II pressure ulcer.

Correct Answer: A

Rationale: The correct answer is A: With a circular motion, to enhance absorption. Applying dexamethasone cream in a circular motion helps distribute the medication evenly and promotes better absorption into the skin. This method ensures that the active ingredients are spread uniformly over the affected area, maximizing the therapeutic effects. Incorrect choices: B: In a thick layer - Applying a thick layer may lead to excessive absorption or wastage of the medication. C: With a downward stroke - Applying in a downward stroke may not distribute the cream evenly and may not facilitate absorption. D: Using a cotton ball only - Using a cotton ball may not provide the necessary pressure to evenly distribute the cream on the skin.

Correct Answer: A

Rationale: The correct answer is A because a nurse who never had German Measles is not at risk of contracting herpes zoster from the client. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which causes chickenpox. If a person has never had chickenpox, they are at risk of getting it from a client with herpes zoster. Roseola and mumps are not related to herpes zoster, so choices C and D are incorrect.