A nurse is assessing a 60-year-old client with psoriasis. Wh… | 마이메르시 MyMerci
Adult Health
문제

A nurse is assessing a 60-year-old client with psoriasis. Which finding would be most characteristic of this condition?

A 45-year-old client presents to the dermatology clinic with skin lesions that have been present for several months.
해설
Psoriasis is characterized by well-demarcated, raised, erythematous plaques with silvery-white scales. Other options describe conditions like impetigo or eczema.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests your ability to identify the classic cutaneous (skin) presentation of Psoriasis. Psoriasis is a chronic, autoimmune, inflammatory skin disorder characterized by an accelerated turnover of skin cells. The normal skin cell life cycle is about 28 days, but in psoriasis, it speeds up to just 3-4 days. This rapid proliferation leads to the accumulation of immature skin cells on the surface, forming the hallmark plaques and scales.

Answer Rationale: Key Point! The most characteristic finding for psoriasis is well-demarcated, raised, erythematous plaques covered with silvery-white scales. "Well-demarcated" means the lesions have a clear border separating them from normal skin. The "silvery-white scales" are the accumulated, immature keratinocytes (skin cells) that are loosely adherent. These plaques are most commonly found on the scalp, elbows, knees, and lower back.

Distractor Analysis: Watch out for confusion! It's crucial to differentiate psoriasis from other common dermatological conditions.
• Option ② describes Impetigo, a highly contagious bacterial skin infection (usually caused by *Staphylococcus aureus* or *Streptococcus pyogenes*) common in children. The "honey-colored crusts" are a classic sign.
• Option ③ is highly suggestive of Melanoma, a dangerous form of skin cancer. The "ABCDE" rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving) helps identify suspicious lesions.
• Option ④ describes the presentation of Contact dermatitis, often from an allergen like poison ivy. The linear pattern occurs when the skin brushes against the offending plant.

Related Concepts: Psoriasis is not just a skin condition; it's a systemic inflammatory disease. Nurses must be aware of associated conditions like Psoriatic arthritis, which causes joint pain and swelling, and the increased risk for cardiovascular disease and metabolic syndrome. Triggers for flare-ups include stress, skin injury (Koebner phenomenon), infections, and certain medications.
Concept SummaryDisease: Psoriasis – Chronic, autoimmune, inflammatory skin disorder.
Pathophysiology: Accelerated keratinocyte (skin cell) turnover (3-4 days vs. normal 28 days).
Hallmark Lesion: Well-demarcated, erythematous plaque with silvery scale.
Common Sites: Scalp, elbows, knees, sacrum (extensor surfaces).
Systemic Link: Associated with psoriatic arthritis, cardiovascular risk, metabolic syndrome.
Nursing Focus: Skin assessment, managing chronic symptoms, patient education on triggers and treatment adherence.
Side-by-Side Comparison!
ConditionKey Skin FindingsEtiology (Cause)Nursing Note
PsoriasisWell-demarcated, raised, red plaques with silvery scalesAutoimmune, genetic, triggered by stress/injuryChronic management, assess for joint pain (psoriatic arthritis)
ImpetigoVesicles/pustules that rupture, forming honey-colored crustsBacterial infection (Staph/Strep)Highly contagious, contact isolation, antibiotic treatment
Eczema (Atopic Dermatitis)Erythematous, dry, itchy patches; may be lichenified (thickened)Complex (immune, genetic, environmental triggers)Intense pruritus (itching), focus on skin hydration and avoiding irritants
Contact DermatitisErythema, papules, vesicles in a pattern matching exposure (e.g., linear)Irritant or allergic reactionIdentify and remove the offending agent (allergen/irritant)

Anatomy, Physiology & Pharmacology PointsSkin Layers: Psoriasis primarily affects the epidermis. The rapid cell division occurs in the stratum basale (basal layer).
Immune Response: Involves T-cells and inflammatory cytokines like Tumor Necrosis Factor-alpha (TNF-α) and Interleukins (IL-17, IL-23).
Common Treatments:
  - Topical: Corticosteroids (reduce inflammation), Vitamin D analogs (slow cell growth), coal tar.
  - Phototherapy: UVB light.
  - Systemic: Methotrexate (immunosuppressant), Cyclosporine.
  - Biologics: Drugs that target specific parts of the immune system (e.g., TNF-α inhibitors, IL-17 inhibitors).
Memory TipsPlaque Psoriasis: Think "Silvery Scales on Salmon-colored Sharp-bordered plaques." (The 4 S's).
Differentiation: "Honey = Infection" (Impetigo). "Linear = Contact" (Contact dermatitis). "Changing mole = Cancer" (Melanoma).
High-Frequency NCLEX Topics Psoriasis is a classic NCLEX topic. You must be able to:
1. Identify the lesion from a description or image.
2. Understand it is a chronic, non-contagious condition (important for patient education and reducing stigma).
3. Recognize common triggers (stress, skin trauma, infection).
4. Know key patient education points for topical medication application (apply to clean, damp skin; use thin layer; rotate potent steroid sites).
Watch Out for Question Variations! • Instead of asking for the finding, the question might ask: "The nurse is teaching a client with psoriasis about skin care. Which statement by the client indicates understanding?" (Correct answer would focus on gentle cleansing, moisturizing, and avoiding picking scales).
• A question could present a client with psoriasis and new joint pain, asking you to identify the development of psoriatic arthritis.
• A medication question might ask about the priority assessment for a patient starting Methotrexate (monitoring for signs of infection and liver toxicity).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: Mr. Johnson, a 60-year-old with a long history of plaque psoriasis, is admitted for an elective knee replacement. During your shift assessment, you note thick, red, scaly plaques covering about 30% of his elbows, knees, and scalp. He mentions the plaques are itchy and he's embarrassed by them.

Nursing Intervention Strategy:
1. Assessment: Use the Psoriasis Area and Severity Index (PASI) as a reference to document location, erythema (redness), induration (thickness), and scaling. Assess for signs of infection (increased warmth, pain, purulent drainage). Inquire about joint pain/stiffness (screening for psoriatic arthritis). Assess the psychosocial impact.
2. Nursing Diagnosis: Impaired Skin Integrity, Chronic Pain, Disturbed Body Image, Risk for Infection.
3. Planning & Implementation:
  - Skin Care: Collaborate to establish a daily routine. Encourage lukewarm (not hot) baths with colloidal oatmeal or bath oils to soften scales. Gently pat dry. Apply prescribed topical medications (e.g., corticosteroid cream) to damp skin to enhance absorption, followed by a thick, fragrance-free emollient (moisturizer) over entire body.
  - Prevent Koebner Phenomenon: Be extremely careful with adhesive dressings, blood pressure cuffs, and IV securement on unaffected skin to avoid triggering new lesions at sites of trauma.
  - Education & Support: Educate that psoriasis is not contagious. Discuss stress management techniques. Provide resources for support groups (National Psoriasis Foundation).
4. Evaluation: Monitor for reduction in scale thickness and erythema, decreased pruritus (itching), and patient verbalization of improved coping and body image.
Nursing Procedure & Medication Flow Applying Topical Corticosteroids for Psoriasis:
1. Assessment: Check provider's order for drug name, strength, frequency, and application site.
2. Preparation: Gather supplies (medication, non-sterile gloves, tongue depressor if from a jar).
3. Procedure:
  a. Don gloves.
  b. Assist patient with gentle cleansing of the area; pat dry.
  c. Apply a thin layer (a pea-sized amount can cover an area the size of two palms) only to the affected plaques. Rub in gently until absorbed.
  d. For potent steroids, educate on site rotation to prevent skin atrophy (thinning).
  e. Remove gloves and perform hand hygiene.
4. Patient Education: Do not cover with occlusive dressings unless specifically ordered. Do not use on face, groin, or axillae unless prescribed for those sensitive areas. Report any signs of skin infection or worsening irritation.
A Word from Your Senior Nurse "Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, a patient with psoriasis might be hospitalized for something completely unrelated (like our Mr. Johnson for his knee). Your skilled skin assessment and knowledgeable care prevent complications like infection from cracked plaques and address the profound psychosocial burden this visible disease carries. When studying for your boards, don't just memorize 'silvery scales' — connect it to the real person. Understand the chronicity, the triggers, and the holistic care needed. That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, compassionate nurse!"

핵심 개념

  • Psoriasis — A chronic autoimmune condition causing rapid skin cell buildup, leading to scaling, inflamed plaques.
  • Plaque — A raised, solid area of skin change >1 cm in diameter; the classic lesion in plaque psoriasis.
  • Koebner Phenomenon — The appearance of new psoriatic lesions at sites of skin injury or trauma.
  • Psoriatic Arthritis — A form of inflammatory arthritis associated with psoriasis, causing joint pain, stiffness, and swelling.
  • Impetigo — A contagious superficial bacterial skin infection characterized by honey-colored crusts.

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