Chapter 22- Assessment: Integumentary System

Which activities can the nurse working in the outpatient clinic delegate to the LPN? (select all that apply) a. administer patch testing on a patient with allergic dermatitis b. interview a new patient about chronic health problems and allergies c. apply a sterile dressing after the health care provider excises a mole d. explain potassium hydroxide testing to a patient with a skin infection e. teach a patient about site care after a punch biopsy of an upper arm lesion

ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in an LPNs education and scope of practice

When performing a skin assessment, the nurse notes angiomas on the chest of an older adult patient. Which action should the nurse take next? a. suggest an appointment with a dermatologist b. assess the patient for evidence of liver disease c. teach the patient about skin changes with aging d. discuss the use of sunscreen to prevent skin cancers

ANS: B Angiomas are a common occurrence as the patient gets older, but they may occur with systemic problems such as liver disease

Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be of concern to the nurse? a. brown macules on extremities b. reports a history of allergic rashes c. skin wrinkled with tenting on both hands d. longitudinal nail ridges and sparse scalp hair

ANS: B Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes

The nurse assess a circular, flat, reddened lesion about 5 cm in diameter on a middle aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. elevate the patient's leg b. press firmly on the lesion c. check the temperature of the skin around the lesion d. palpate the dorsalis pedis and tibial pulses

ANS: B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion

A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should the nurse expect? a. hypertrophied scars on both ankles b. thickening of the skin around the ankles c. yellowish brown skin around both ankles d. complete absence of melanin in both ankles

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin often

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions of the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. confluent b. symmetric c. zosteriform d. gereralized

ANS: B The description of the lesions indicates that they are grouped in bilateral distribution

A patient in the dermatology clinic is scheduled for removal of a 15 mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. shave biopsy b. punch biopsy c. incisional biopsy d. excisional biopsy

ANS: C An incisional biopsy would remove the entire mole and the tissue borders

A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How should the nurse assess the patient for cyanosis? a. assess the skin color of the earlobes b. apply pressure to the palms of the hands c. check the lips and oral mucous membranes d. examine capillary refill time of the nail beds

ANS: C Cyanosis persons with dark skin is more easily seen in the mucous membranes

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. sterile gloves b. patch test instruments c. cotton tipped applicators d. syringe and intradermal needle

ANS: C Fungal cultures are obtained by swabbing the affected area of the skin with cotton tipped applicators

Which abnormality on the skin of an older adult patient is the priority for the nurse to discuss with the health care provider? a. dry, scaly patches on the face b. numerous varicosities on both legs c. petechiae on the chest and abdomen d. small dilated blood vessels on the face

ANS: C Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies

The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action should the nurse take first? a. ensure the patient wears should with nonslip soles b. discourage using throw rugs throughout the house c. talk with the patient alone and ask about the bruising d. suggest that the health care provider prescribe radiographs

ANS: C The nurse should note irregular patterns of bruising, especially in the shape of hands or fingers, in different stages of resolution

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin, thin hair, and thick, brittle nails. What is the nurse's most important action? a. instruct the patient about the importance of nutrition for skin health b. make a referral to the podiatrist so that the nails can be safely trimmed c. consult with the health care provider about the need for further diagnostic testing d. teach the patient about using moisturizing creams and lotions to decrease dry skin

ANS: C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated

The nurse notes darker skin pigmentation in the skinfolds of a middle aged patient who has a BMI of 40. What is the nurse's appropriate action? a. discuss the use of drying agents to minimize infection risk b. instruct the patient about the use of mild soap to clean skinfolds c. teach the patient about treating fungal infections in the skinfolds d. ask the patient about a personal or family history of type 2 diabetes

ANS: D The presence of acanthosis nigricans in skinfolds suggests either having type 3 diabetes or being at risk for it

The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 year. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations? (select all that apply) a. vitiligo b. alopecia c. intertrigo d. erythema e. actinic keratosis

ANS: D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis