The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
Thick skin plaques topped by silvery white scales
Tenderness upon palpation and generalized erythema
Brown, rough, greasy, wart-like papules on the face.
Requires sunglasses because sunlight hurts eyes.
The Correct Answer is D
A. Thick skin plaques topped by silvery white scales:
This is a characteristic presentation of psoriasis vulgaris, not an indicator of overexposure to PUVA.
B. Tenderness upon palpation and generalized erythema:
This may be associated with various skin conditions but is not specific to overexposure to PUVA.
C. Brown, rough, greasy, wart-like papules on the face:
This description is not consistent with the expected outcomes or side effects of PUVA treatment.
D. Requires sunglasses because sunlight hurts the eyes.
PUVA treatment involves the use of psoralen, a light-sensitizing medication, followed by exposure to ultraviolet A (UVA) light. Overexposure to PUVA can lead to phototoxic reactions, including eye sensitivity to sunlight (photophobia). If the client requires sunglasses because sunlight hurts the eyes, it suggests that the eyes have been affected by the treatment, and the nurse should intervene to prevent further damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instruct the client to drink plenty of fluids during the treatment.
This option focuses on hydration, which is generally important during chemotherapy to flush out toxins and maintain overall health. However, it does not specifically address the risk of vesicant extravasation.
B. Keep the head of the bed elevated until the treatment is completed.
Keeping the head of the bed elevated is a measure that may be taken for certain conditions or treatments, but it is not directly related to preventing vesicant extravasation.
C. Monitor the client's intravenous site hourly during the treatment.
This is the correct choice. Monitoring the intravenous site for signs of extravasation, such as swelling, redness, or pain, is crucial when administering vesicant chemotherapy drugs. Early detection allows for prompt intervention to minimize potential tissue damage.
D. Administer an antiemetic before starting the chemotherapy.
Administering an antiemetic (a medication to prevent or alleviate nausea and vomiting) is important for managing side effects of chemotherapy, but it does not specifically address the prevention of vesicant extravasation.
Correct Answer is D
Explanation
A. Have the client sign the surgical and transfusion permits:
While obtaining signed consent is important, the immediate concern is addressing the client's medication history, especially the use of heparin, which can contribute to bleeding.
B. Ensure that the potential for bleeding is explained to the client:
Education about the potential for bleeding is important, but the immediate action is to communicate the client's medication history to the healthcare provider for appropriate guidance.
C. Observe the heparin injection sites for signs of bruising:
Monitoring for bruising at injection sites is a consideration, but it is not the priority when the client is actively bleeding from an open fracture.
D. Notify the healthcare provider of the client's medication history:
This is the correct answer. Heparin is an anticoagulant, and its use can increase the risk of bleeding during surgery. The healthcare provider needs to be informed of the client's current medication history to make decisions regarding the timing and management of heparin therapy in the perioperative period.
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