Skin Conditions and Treatments, Exams of Nursing

Download Skin Conditions and Treatments and more Exams Nursing in PDF only on Docsity! HOSMERIT APEA 3P - DERMATOLOGY EXAM QUESTIONS WITH CORRECT ANSWERS & RATIONALES GRADED A+ Impetigo is characterized by: a. honey-colored crusts. b. silvery scales. c. marble-like lesions. d. wheals with pus. A. Impetigo is a superficial bacterial infection of the skin characterized by honey- colored crusts. Another form of impetigo is characterized by the presence of bullae. These infections are treated with topical antibiotics, good hygiene, and frequent hand washing. It is usually caused by Staphylococcus or Group A Streptococcus. A patient was burned with hot water. He has several 2-3 cm fluid-filled lesions. What are these termed? a. Vesicles b. Bullae c. Cysts d. Wheals B. Bullae are fluid-filled lesions that are greater than 6 mm in diameter. These are common in patients who have a superficial partial-thickness burn. Vesicles are also fluid filled, but they are smaller than 5 mm in diameter. A cyst is enclosed in a sac that can contain fluid or gelatinous material. Wheals are erythematous, irregular raised areas on the skin. All of these are termed primary lesions. The best way to evaluate jaundice associated with liver disease is to observe: a. blanching of the hands, feet, and nails. b. the sclera, skin, and lips. c. the lips, oral mucosa, and tongue. d. tympanic membrane and skin only. B. Looking at the sclera allows the examiner to see jaundice most easily and reliably. Jaundice may also appear in the palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane, and skin. Jaundice in adults usually is a result of liver disease, but it can be due to excessive hemolysis of red blood cells. In infants, the usual cause is hemolysis of red blood cells, as is seen in physiologic jaundice. The most common place for a basal cell carcinoma to be found is the: a. scalp. b. Face. c. Ear. d. Anterior shin. B. The most common presentation of basal cell carcinoma (BCC) is on the face. This is probably because BCC occurs secondary to sun damage. The most common sun exposure occurs on the face. In fact, 70% of BCC occurs on the face; 15% occurs on the trunk. A topical treatment for basal cell carcinoma is: a. sulfacetamide lotion. b. 5-fluorouracil. Recurrences are common. Seborrheic dermatitis affects only hairy areas of the body. The vesicles might raise suspicion of a viral infection, but this is not present in this case. A 71-year-old female presents with a vesicular rash that burns and itches. Shingles is diagnosed. An oral antiviral: a. should be started within 72 hours of the onset of symptoms. b. must be started within 96 hours of the onset of the rash. c . can be started at any time after the appearance of the rash. d. will nearly eliminate the risk of postherpetic neuralgia. A. This patient has been diagnosed with shingles. This can produce painful neuritis. Shingles is treated with an oral antiviral agent, preferably within 72 hours of onset of the symptoms. Treating shingles with an oral antiviral agent shortens the severity and duration of shingles. It may also help decrease the incidence of post-herpetic neuralgia. A patient presents with plaques on the extensor surface of the elbows, knees, and back. The plaques are erythematous and thick, silvery scales are present. This is likely: a. plaque psoriasis. b. guttate psoriasis. c. atopic dermatitis. d. Staph cellulitis. A. Plaque psoriasis is seen initially in young adults and is characterized as described above. The thick, silvery scale is pathognomic and is usually asymptomatic, but some patients will complain of pruritus. A clinical finding that will help establish a diagnosis is the pitting of fingernails. This occurs in about 50% of patients with psoriasis. The plaques are commonly distributed on the scalp, and extensor surface of the elbows, knees, and back. This is a chronic skin disorder. The nurse practitioner examines a patient who has had poison ivy (hiedra venenosa) for 3 days. She asks if she can spread it to her family members. The nurse practitioner replies: a. “Yes, but only before crusting has occurred.” b. “Yes, the fluid in the blister can transmit it.” c. “No, the transmission does not occur from the blister’s contents.” d. “No, you are no longer contagious.” C. The skin reaction seen after exposure to poison ivy (hiedra venenosa), takes place because of contact with the offending substance. In the case of poison ivy, the harmful exposure occurs from contact with oil from the plant. The eruptions seen are NOT able to transmit the reaction to other people unless oil from the plant remains on the skin and someone touches the oil. The fluid found in the blisters is NOT able to transmit poison ivy to anyone; only the oil from the plant can do that. After the oil has touched the skin, some time must pass for the reaction to occur. Therefore, reaction times vary depending on skin thickness and the quantity of oil contacting the skin. A “herald patch” is a hallmark finding in which condition? a. Erythema infectiosum b. Pityriasis rosea c. Seborrheic keratosis d. Atopic dermatitis B. Pityriasis rosea (PR) is a self-limiting exanthematous skin disorder characterized by several unique findings. It is more common in young adults. A characteristic finding is the “herald” or “mother” patch found on trunk. This looks like a ringworm and precedes the generalized “Christmas tree” pattern rash. The lesions associated with the rash are salmon-colored and oval in shape. Most cases clear in 4-6 weeks, but the plaques may last for several months. A patient with diabetes has right anterior shin edema, erythema, warmth, and tenderness to touch. This developed over the past 3 days. There is no visible pus. What is the most likely diagnosis to consider? a. Deep vein thrombosis (DVT) b. Buerger’s disease c. Cellulitis d. Venous disease C. This description is one of cellulitis. Cellulitis involves an infection of the subcutaneous layers of the skin. It must be treated with an oral antibiotic. In a patient with diabetes, it is particularly important to identify, and aggressively treat cellulitis early, because elevated blood sugar levels will make eradication more difficult. Buerger’s disease involves inflammation of the medium-sized arteries and does not present on the anterior shin only. DVT seldom presents on the anterior shin, so this is not likely. Venous disease does not present acutely, as in this situation. An example of a premalignant lesion that develops on sun-damaged skin is: a. actinic keratosis. b. basal cell carcinoid. c. squamous cell carcinoma. d. molluscum contagiosum. A. Actinic keratoses (AK) are a result of solar damage to the skin. They are most common on the face, bald scalp, and forearms. Patients who present with AK usually have multiple of them. A characteristic that helps identification of AK is an area of erythema that surrounds the lesion. AK is sometimes easier felt than seen. A patient calls your office. He states that he just came in from the woods and discovered a tick on his upper arm. He states that he has removed the tick and the area is slightly red. What should he be advised? d. Clean the wounds, provide tetanus and rabies prophylaxis. e. Report the bite to animal control and administer appropriate medical care. D. All 50 states require reporting of animal bites to animal control or the state’s appropriate authority for reporting animal bites. It sounds unlikely that the dog could be infected with rabies, but rabies prophylaxis must be considered after all history and information has been gathered. A 16-year-old has been diagnosed with Lyme disease. Which drug should be used to treat him? a. Doxycycline b. Amoxicillin-clavulanate c. Trimethoprim-sulfamethoxazole d. Cephalexin A. Doxycycline is frequently chosen first-line to treat Lyme disease. However, numerous studies have demonstrated that amoxicillin and cefuroxime have equal efficacy as doxycycline in the treatment of early Lyme disease. These drugs are recommended in patients who exhibit erythema migrans. Doxycycline is not recommended in children younger than 9 years of age. Which test is NOT suitable to diagnose shingles if the clinical presentation is questionable? a. Tzanck preparation b. Polymerase chain reaction (PCR) c. Direct fluorescent antibody (DFA) d. Complete blood count (CBC) D. Herpes viruses are the causative agents in shingles, chickenpox, genital herpes, and oral fever blisters. Diagnosis is usually made on clinical presentation. However, in questionable cases, lab tests may be employed. A Tzanck preparation is a rapid test used to diagnose infections due to herpes viruses. Cells taken from a blister’s fluid are smeared on a slide and stained with a Wright’s stain, or the fluid can be used for other methods of testing. DFA is the most common test employed for shingles diagnosis because it can be rapidly performed and offers results in about 90 minutes. PCR may be performed on skin scrapings, serum or blood for herpetic diagnosis. CBC may indicate a patient with a viral infection, but it is nonspecific for herpetic infections. A 68-year-old female adult with pendulous breasts complains of “burning” under her right breast. The nurse practitioner observes a malodorous discharge with mild maceration under both breasts. What is this? a. Intertrigo b. Impetigo c. Tinea corporis d. Shingles A. This is not unusual in adults with pendulous breasts. Intertrigo is common in areas between skin folds, under the breasts, between the scrotum and inner thigh, or between the toes. These are moist lesions that can be easily treated if the skin can be separated from touching the adjoining skin and the area can be kept dry. A topical powder with an antifungal would likely resolve this if used twice daily for 7- 14 days. A diagnosis of diabetes should be considered if this is resistant to treatment or if it recurs. A 70-year-old is diagnosed with multiple cherry angiomas. The nurse practitioner knows that: a. this is a mature capillary proliferation more common in young adults. b. an angioma occurs as a single lesion. c. these may bleed profusely if ruptured. d. these are precursors of skin malignancies. C. Cherry angiomas are mature capillary proliferations that are more common in middle- aged and older adults. They blanch with pressure and are usually 0.1-0.4 cm in diameter. They are commonly found on the trunk as multiple lesions. Because they are a proliferation of capillaries, they will bleed significantly if they rupture. The bleed is not life threatening, but in older adults who take aspirin, the bleeding will be worse. Pressure should be held over the ruptured area until bleeding stops. These are not precursors of skin malignancies. Which of the following antibiotics may increase the likelihood of photosensitivity? a. Amoxicillin b. Cephalexin c. Ciprofloxacin d. Azithromycin C. Many medications can produce a phototoxic reaction when a patient is exposed to sunlight. Antibiotics are especially notable for this. Common antibiotics associated with photosensitivity are tetracyclines, sulfa drugs, and fluoroquinolones. Ciprofloxacin is a fluoroquinolone. Amoxicillin and cephalexin are beta lactam antibiotics. Azithromycin is a macrolide antibiotic. Other common medications/classes that increase photosensitivity are hydrochlorothiazide, diltiazem, selective serotonin reuptake inhibitors, antihistamines, ibuprofen, and naproxen. The primary therapeutic intervention for patients who present with hives is: a. steroids. b. antihistamines. c. calcium channel blockers. d. topical steroid cream. B. The primary cause of pruritus associated with hives is histamine release. Histamine is released from mast cells with other substances of anaphylaxis. Antihistamines are the primary therapeutic intervention. Topical steroid use is not helpful. Calcium channel blockers (nifedipine) are used as a “last resort” for refractory cases of urticaria. Steroids do not inhibit mast cell degradation and so are less helpful than thought. Steroids can be used for persistent attacks of acute urticaria if antihistamines are not helpful. d. Cherry angioma C. Blanching with pressure over spider angiomas always occurs. Spider veins and cherry angiomas usually blanch with pressure. Purpura and petechiae never blanch with pressure. Purpura and petechiae represent the extravasation of blood under the skin. These will not blanch when pressure is applied. This is usually observed in patients with thrombocytopenia or trauma. A 74-year-old woman is diagnosed with shingles. The NP is deciding how to best manage her care. What should be prescribed? a. An oral antiviral agent b. An oral antiviral agent plus an oral steroid c. An oral antiviral agent plus a topical steroid d. A topical steroid only A. An oral antiviral agent such as acyclovir, famciclovir or valacyclovir should be prescribed, especially if it can be initiated within 72 hours after the onset of symptoms. The addition of oral corticosteroids to oral antiviral therapy demonstrates only modest benefits. Adverse events to therapy are more commonly reported in patients receiving oral corticosteroids. There is no evidence that corticosteroid therapy decreases the incidence or duration of postherpetic neuralgia or improves the quality of life. Corticosteroids should be limited to use in patients with acute neuritis who have not derived benefits from opioid analgesics. An example of a first-generation cephalosporin used to treat a skin infection is: a. cephalexin. b. cefuroxime. c. cefdinir. d. cefaclor. A. Two common first-generation cephalosporins used to treat skin and skin structure infections are cephalexin and cefadroxil. These are taken two to four times daily and are generally well tolerated. These antibiotics provide coverage against Staphylococcus and Streptococcus, common skin pathogens. A patient is diagnosed with tinea pedis. A microscopic examination of the sample taken from the infected area would likely demonstrate: a. hyphae. b. yeasts. c. rods or cocci. d. a combination of hyphae and spores. A. Under microscopic exam, hyphae are long, thin and branching, and indicate dermatophytic infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis. Yeasts are usually seen in candidal infections. Cocci and rods are specific to bacterial infections. A patient has been diagnosed with MRSA. She is allergic to sulfa. Which medication could be used to treat her? a. Augmentin b. Trimethoprim-sulfamethoxazole (TMPS) c. Ceftriaxone d. Doxycycline D. MRSA is methicillin-resistant Staph aureus. This is very common in the community and is typically treated with sulfa medications like TMP/SMX (Bactrim DS and Septra DS). If the patient is allergic to sulfa, this should not be used. A narrow-spectrum antibiotic that can be used is doxycycline or minocycline. It is given twice daily and is generally well tolerated. MRSA is resistant to the antibiotics in the other choices and so they should NOT be used to treat it. Which vehicle is least appropriate in a patient who has atopic dermatitis? a. Lotions b. Creams c Thick creams d. Ointments A. Patients who have atopic dermatitis need continuous skin hydration. Lotions can worsen xerosis (dry skin) due to evaporation of water on the skin. In contrast to creams and ointments, lotions have a high water content and a low oil content. Creams have a lower water content. Ointments have no water and are excellent agents to use on dry skin as well as to prevent dry skin. A 23-year-old male appears in clinic with the following nonpruritic lesion on his trunk. He first noticed this about 3 days ago. The lesion is probably: a. scabies. b. eczema. c. a herald patch. d. psoriasis. C. Pityriasis rosea is a viral rash that is common in older children and young adults. It typically begins with a herald patch, a single round pink or salmon-colored, nonpruritic plaque on the chest, neck, or back. It is often mistaken for ringworm prior to the eruption of the Christmas tree pattern rash. The rash occurs within 1-2 weeks after the appearance of the herald patch. Scabies typically presents as a pruritic eruption characterized by small, erythematous, nondescript papules. Its prominent clinical feature is pruritus. Most cases of eczema initially occur by the age of five years, but can manifest in adults as an c. diabetes. d. hypothyroidism. A. A herald patch is usually located on the trunk and associated with pityriasis rosea. It precedes the generalized Christmas tree pattern rash. Folliculitis is a superficial infection of the hair follicles. It presents as clusters of small, raised, erythematous lesions, not as a singular lesion as demonstrated in this image. Diabetes may be associated with acanthosis nigricans, a condition characterized by areas of velvety, hyperpigmented skin most commonly on the body folds and skin creases such as the neck and axillae. Hypothyroidism is not associated with this lesion. What finding is most characteristic of shingles? a. Pain, burning, and itching b. Single dermatome affected c. Presence of grouped vesicles d. Presence of rash and crusting B. Shingles is herpes zoster. It characteristically affects a single dermatome. Grouped vesicles on an erythematous base may occur in some patients with shingles, but this is not unique to shingles. In fact, it is typical in many viral infections. Crusting may be seen with shingles, chicken pox, or impetigo. Pain, burning, and itching are symptoms that some patients have with shingles, but not all patients report itching with shingles. A patient has used a high-potency topical steroid cream for years to treat psoriasis exacerbations when they occur. She presents today and states that this cream “just doesn’t work anymore.” What word describes this? a. Rebound effect b. Tachyphylaxis c. Tolerance d. Lichenification B. Tachyphylaxis is the word used to describe a gradual and progressively poorer clinical response to a treatment or medication. This is particularly true of topical glucocorticoids, bronchodilators, nitroglycerine, and antihistamines when they are overused. The rebound effect describes a condition in which initial clinical improvement occurred, but worsening has occurred. Lichenification refers to a thickening of the skin. Drug-free intervals are important to prevent tachyphylaxis. A low-potency topical hydrocortisone cream would be most appropriate in a patient who has been diagnosed with: a. psoriasis. b. impetigo. c. cellulitis. d. atopic dermatitis. D. Low-potency steroid creams are almost never potent enough to treat psoriasis. Psoriasis requires higher-potency steroid preparation or systemic agents. Impetigo is a superficial bacterial infection, and a steroid cream would be contraindicated. Cellulitis is an infection of the subcutaneous layer of the skin and requires an oral or systemic antibiotic. Atopic dermatitis is a chronic inflammatory disorder of the skin that involves a genetic defect in the proteins supporting the epidermal layer. A patient with atopic dermatitis would be the most appropriate (of those listed above) to use a low- potency topical steroid cream. Mr. Johnson is a 74-year-old who presents with a pearly-domed, nodular-looking lesion on the back of the neck. It does not hurt or itch. What is a likely etiology? a. Basal cell carcinoma b. Squamous cell carcinoma c. Malignant melanoma d. Actinic keratosis A. Basal cell’s classic description is “a pearly-domed nodule with a telangiectatic vessel”. It is commonly found on sun-exposed areas like the head or neck. Sending the patient to dermatology (since these represent skin cancer) best treats these lesions. Sometimes these lesions can be treated with a topical agent like 5- fluorouracil if they are superficial; others require surgical removal. The main difference between cellulitis and erysipelas is the: a. age of the patient. b. length of time that infection lasts. c. treatment. d. layer of skin involvement. D. Erysipelas and cellulitis both cause skin erythema, edema, and warmth. However, erysipelas involves the upper dermis and superficial lymphatics; cellulitis involves the deeper dermis and subcutaneous fat. Erysipelas is usually caused by Streptococcus; cellulitis may be caused by Staphylococcus and less commonly by Streptococcus.