As a home health nurse, you are developing the care plan for an elderly client who has just been referred to your agency. One of the nursing diagnoses is Impaired Skin Integrity related to poor nutrition, bladder incontinence, and immobility. Which of the following nursing actions is best to delegate to an experienced nursing assistant who works at the agency?

Correct Answer: C

Rationale: In this scenario, the best nursing action to delegate to an experienced nursing assistant is option C, which is to remind the family to help the client to the commode every 2 hours during the day. This action directly addresses the factors contributing to impaired skin integrity, such as immobility and bladder incontinence. Option A would require more specialized knowledge and skill to ensure proper application of skin barrier cream. Option B involves assessing and making recommendations regarding the client's nutrition, which falls more under the scope of a nurse's responsibilities. Option D involves evaluating and documenting improvements in skin integrity, which requires nursing assessment and clinical judgment. Educationally, it's important to understand the principles of delegation in nursing practice. Delegating tasks to nursing assistants should be based on their skill level, the complexity of the task, and the client's condition. By delegating appropriate tasks, nurses can optimize efficiency and ensure quality care for clients while promoting teamwork within the healthcare team.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Long-standing cardiopulmonary disease. When the angle between the nail base and the skin, known as the Lovibond angle, exceeds 160°, it is called "clubbing." Clubbing of the nails is a clinical sign associated with various underlying medical conditions, with long-standing cardiopulmonary diseases being a significant cause. In cardiopulmonary diseases like chronic obstructive pulmonary disease (COPD) or congenital heart defects, clubbing occurs due to chronic hypoxia and tissue hypoxia, leading to changes in the nail bed vasculature and connective tissue. Option A) Poor circulation is not the most likely cause in this scenario because clubbing specifically points towards chronic conditions affecting the heart and lungs rather than just poor circulation alone. Option B) Iron deficiency anemia is also not the correct answer in this case, as it is not typically associated with the physical presentation of clubbing. Iron deficiency anemia can manifest with other nail changes like koilonychia (spoon-shaped nails) but not clubbing. Option D) Fungal infection is an incorrect choice as well because fungal infections of the nails typically present with changes in nail color, texture, and thickness, rather than altering the angle between the nail base and skin. Educational context: Understanding physical assessment findings like nail clubbing is crucial for healthcare professionals, especially nurses, as it can provide valuable clues to an underlying systemic condition. Recognizing clubbing early can prompt further investigations and timely interventions for conditions like cardiopulmonary diseases. This knowledge enhances the nurse's ability to monitor patients effectively, collaborate with the healthcare team, and provide holistic care.

Correct Answer: A

Rationale: Educational Rationale: The correct answer is A) A thorough washing of the hands. Benzoyl peroxide, commonly used in acne preparations, is a bleaching agent that can cause fabric discoloration upon contact. Instructing the client to thoroughly wash their hands after applying the medication is essential to prevent the transfer of benzoyl peroxide to clothing or other fabrics, thereby reducing the risk of discoloration. Option B) A thorough bath after the medication is incorrect because the primary concern is preventing the transfer of benzoyl peroxide to fabrics, which can be effectively addressed by washing the hands only. Option C) Wear disposable clothes is not necessary if the client follows proper hand hygiene practices as instructed in Option A. Option D) Wear disposable plastic gloves is excessive for the application of acne preparations containing benzoyl peroxide. It is more practical and sufficient for the client to wash their hands thoroughly after application. Educational Context: Understanding the side effects and proper handling of medications is crucial for both healthcare providers and patients. In the case of benzoyl peroxide, awareness of its bleaching properties and the necessary precautions can prevent unintended fabric discoloration. This question highlights the importance of patient education regarding the safe use of topical medications and the simple yet effective measures that can be taken to mitigate potential issues.

Correct Answer: B

Rationale: The correct answer is B) Apply sunscreen with a high SPF when outdoors. This instruction is important because UV radiation can cause hyperpigmentation of the newly healed skin, leading to increased scarring. Sunscreen helps protect the delicate new skin from harmful UV rays, which is crucial for optimal healing and scar prevention. Option A) Wear thick clothes is incorrect because while clothing can offer some protection from the sun, it is not as effective as sunscreen in providing broad-spectrum protection. Also, thick clothing may not be comfortable or practical for the client. Option C) Avoid use of topical gels is incorrect because certain topical gels, especially those prescribed by healthcare providers, can aid in wound healing and scar prevention. Avoiding them completely may hinder the healing process. Option D) Avoid cold water baths is incorrect because cold water can actually help soothe the skin and reduce inflammation following skin grafting. However, prolonged exposure to cold water or extreme temperatures should be avoided. In an educational context, understanding the importance of proper post-burn care is essential for nurses and healthcare providers. Providing accurate instructions to clients post-skin grafting can significantly impact their healing outcomes and overall well-being. It is vital to educate clients on best practices to minimize scarring and promote optimal healing after such procedures.

Correct Answer: B

Rationale: The correct answer to the question is B) Basal cell carcinoma. Basal cell carcinoma is the most common type of skin cancer and is characterized by pearly borders. Understanding this distinction is crucial for early detection and effective treatment. Actinic keratosis (Option A) is a precancerous skin condition that can progress to squamous cell carcinoma but does not typically have pearly borders. Malignant melanoma (Option C) is another type of skin cancer that is known for its irregular borders and dark coloration, not pearly borders. Squamous cell carcinoma (Option D) often presents as a scaly or crusty bump and does not typically have pearly borders like basal cell carcinoma. Educationally, knowing the characteristics of different types of skin cancer is important for healthcare professionals, especially those in dermatology or primary care settings. Recognizing the distinct features of each type can aid in accurate diagnosis, appropriate management, and patient education regarding skin cancer prevention and early detection strategies.