A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?

Herpes zoster

Dermatophytosis

Contact dermatitis

Cellulitis

Answer and Explanation

The Correct Answer is D

A) Herpes zoster
This condition, also known as shingles, is characterized by a painful, blistering rash that follows a nerve path. It typically presents as grouped vesicles rather than generalized edema and erythema, making it unlikely in this case.

B) Dermatophytosis
Commonly known as ringworm, this fungal infection usually causes a scaly, ring-shaped rash. It does not typically present with significant edema or erythema as seen with cellulitis, and tenderness is less common.

C) Contact dermatitis
This allergic or irritant reaction usually causes itching, redness, and rash after contact with a substance. While it can cause erythema and pain, it is less likely to cause the significant edema and tenderness observed in cellulitis.

D) Cellulitis
Cellulitis is a bacterial skin infection characterized by edema, erythema, tenderness, and pain. These symptoms align with the nurse’s findings, indicating an inflammatory response in the deeper layers of the skin, often requiring antibiotic treatment.

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Correct Answer is B

Explanation

A) "Wash hands for 10 seconds after caring for the client.": Proper hand hygiene is critical in preventing the spread of infections, but the recommended duration for handwashing is at least 20 seconds. This option does not specify the necessary steps to ensure effective hand hygiene.

B) "Monitor the client for manifestations of dehydration.": Older adults are at a higher risk of dehydration due to gastroenteritis, which can cause significant fluid loss through vomiting and diarrhea. Monitoring for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and reduced urine output, is a priority in managing their condition and preventing complications.

C) "Use toilet paper to remove stool from the client's skin.": While keeping the client clean is important, using toilet paper might not be sufficient or gentle enough to effectively clean and protect the skin. Using appropriate cleansing methods and skin care products is better for maintaining skin integrity.

D) "Administer diphenoxylate/atropine to the client.": While this medication can help reduce diarrhea, it may not be the first action to take. In some cases, stopping diarrhea too quickly can prevent the elimination of harmful pathogens. Monitoring and addressing hydration status is more critical initially in the management of gastroenteritis.

A. Painful vesicles along a dermatome B. Acneiform nodules on the face C. Wheals surrounding raised bite marks D. Raised, linear burrows

Correct Answer is D

Explanation

A) Painful vesicles along a dermatome:
This finding is typically associated with herpes zoster (shingles), not scabies. Shingles causes painful vesicles that follow the path of a nerve and are confined to one side of the body, which does not align with the presentation of scabies.

B) Acneiform nodules on the face:
Acneiform nodules are related to conditions such as acne vulgaris, not scabies. Scabies does not typically present with acne-like lesions on the face but rather with intense itching and a specific rash.

C) Wheals surrounding raised bite marks:
Wheals and bite marks are more indicative of insect bites or conditions like urticaria (hives). Scabies is caused by mites that burrow under the skin, leading to a different type of rash.

D) Raised, linear burrows:
Raised, linear burrows are characteristic of scabies. These burrows are caused by the female mite as it tunnels just under the skin to lay eggs, resulting in a distinctive rash and intense itching, especially at night.

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A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?

Nursing Test Bank

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