Ch. 22 Assessment of Integumentary System

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse? Select all. a. administer patch testing to a patient with allergic dermatitis b. interview a new patient about chronic health problems and allergies. c. apply sterile dressing after the HCP excises a mole d. teach a patient about site care after a punch biopsy of an upper arm lesion e. explain potassium hydroxide testing to a patient with a superficial skin infection

a, c

When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next? a. assess the patient for evidence of liver disease b. discuss the adverse effects of sun exposure on the skin c. teach the patient about possible skin changes with aging d. suggest that the patient make an appointment with a dermatologist.

a. assess the patient for evidence of liver disease rationale: angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease.

What is the most common diagnostic test used to determine a causative agent of skin infections a. culture b. tzanck test c. immunoflourescent studies d. potassium hydroxide (KOH) slides

a. culture

The patient is visiting the free clinic to refill her medications. During the generalized assessment, the nurse documents alopecia: an increased heart rate; warm, moist, flushed skin; and thin nails. The patient also states she is anxious and has lost weight lately. Which systemic problem will the nurse most likely suspect and relate to the HCP. a. hyperthyroidism b. systemic lupus erythematosus c. vitamin B1 (thiamine) deficiency d. HIV infection

a. hyperthyroidism

The nurse is assessing a white patients skin color for cyanosis. The best place for the nurse to assess this is the a. lips b. legs c. wrists d. sclera

a. lips

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as a. petechiae b. erythema c. ecchymosis d. telangiectasia

a. petechiae

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse a. reports a history of allergic rashes b. scattered macular brown areas on extremities c. skin brown and wrinkled, skin tenting on forearm d. longitudinal nail bed ridges noted; sparse scalp hair

a. reports a history of allergic rashes. rationale: when receiving antibiotics, it is important to know the history of allergic rashes.

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient a. tiny purple spots on the skin b. large ecchymotic areas on the skin c. hyperkeratotic papules and plaques d. small, raised red areas on the soles of the feet.

a. tiny purple spots on the skin

A woman calls the health clinic and describes a rash that she has over the abdomen and chest. She tells the nurse it has raised, fluid filled, small blisters that are distinct a. Identify the type of primary skin lesion described by the patient. b. what is the distribution terminology for these lesions c. What additional information does the nurse have to document the critical components of these lesions

a. vesicles b. discrete, localized to the chest and abdomen c. color, size, height, shape, configuration, and odor.

The nurse is performing an assessment of a patient with obesity. Inspection reveals the presence of a foul odor that emanates from the patients abdominal skin folds. What is most likely causing the odor. a. ecchymosis b. colonization by yeast or bacteria c. age-related integumentary changes d. atrophy of the skin under the abdominal folds

b. colonization by yeast or bacteria

The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system? a. Diuretic b. corticosteroid c. benzodiazepine d. calcium channel blocker

b. corticosteroid

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patients caregiver that the patient has intertrigo. When the caregiver ask what that is, the nurse should tell the caregiver that it is: a. thickening of the skin b. dermatitis in the folds of her skin c. loss of color in diffuse areas of her skin d. a firm plaque caused by fluid in the dermis

b. dermatitis in the folds of her skin

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the best documentation of this problem. a. scales b. fissure c. pustule d. comedo

b. fissure

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patients mouth. The nurse would document this finding as a. scar b. fissure c. atrophy d. excoriation

b. fissure

A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask? a. Is your sleep interrupted by severe episodes of itching at night? b. have you noticed any changes in the way sores or wounds heal? c. Do you have any skin lesions that have changed in size or shape d. what changes if any have you noticed in your skin, hair and nails?

b. have you noticed any changes in the way sores or wounds heal? rationale: a patient with diabetes is more susceptible to poor wound healing

The nurse observes that redness remains after palpation of the discolored lesion on the patients leg. This finding is characteristic of what? a. varicosities b. intradermal bleeding. c. dilated blood vessels d. erythematous lesions

b. intradermal bleeding.

The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient a. it is used for a superficial lesion b. it provides a full-thickness of skin c. It is used for good cosmetic results d. it is used because the lesion is too large to remove

b. it provides a full-thickness of skin

A 38-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be more important for the nurse to obtain? a. history of sun exposure b. method of birth control used by the patient c. length of time the patient has used fluorouracil d. appearance of the treated areas on the patients face

b. method of birth control used by the patient rationale: fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control

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

b. press firmly on the lesion rationale: 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 has a plaque lesion on the dorsal forearm. Which type of biopsy is most likely to be used for diagnosis of the lesion a. punch biopsy b. shave biopsy c. incisional biopsy d. excisional biopsy

b. shave biopsy

The patient asks the nurse what telangiectasia looks like. Which is the best description for the nurse to give the patient? a. A circumscribed, flat discoloration b. small, superficial, dilated blood vessels c. benign tumor of blood or lymph vessels d. tiny purple spots resulting from tiny hemmorrhages

b. small, superficial, dilated blood vessels

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will 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

b. thickening of the skin around the ankles

When assessing an African American patient, the nurse notes ashen color of the nail beds. What should the nurse do next? a. palpate for rashes on the legs. b. assess for jaundice in the sclera of the eye c. assess the mucous membranes for cyanosis d. assess for pallor of the skin on the buttocks.

c. assess the mucous membranes for cyanosis.

A dark skinned patient has been admitted to the hospital with chronic hear failure. How would the nurse best assess this 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.

c. check the lips and oral mucous membranes

A patient is admitted to the acute care facility with purpura. Which laboratory test would be most important to check in the patient a. urinalysis b. serum electrolytes c. coagulation studies d. white blood cell count

c. coagulation studies

The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient. a. lips b. earlobe c. conjunctiva d. palm of hand

c. conjunctiva

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. local anesthetic, syringe, and intradermal needle.

c. cotton-tipped applicators

When the nurse is assessing the skin of an older patient, which factor is likely to contribute to dry skin a. increased bruising b. excess perspiration c. decreased extracellular fluid d. chronic ultraviolet light exposure

c. decreased extracellular fluid

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

c. incisional biopsy

A patient with diabetes has been diagnosed with peripheral vascular disease. Which dermatologic manifestations should the nurse assess? a. Redness of exposed areas of the skin on the hand, foot, face, or neck b. leathery, brownish skin on lower leg, pruritus, concave lesions with edema, scar tissue with healing c. loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing d. atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

c. loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing

When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system? a. decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails. b. decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation c. muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply d. increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

c. muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

The nurse is assessing a patients skin temp, turgor, moisture, and texture. What is the best technique for the nurse to use to obtain the data. a. inspection of skin color b. examination for vascularity c. palpation of skin with the hand d. percussion of the skin on the back

c. palpation of skin with the hand.

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first a. discourage the use of throw rugs throughout the house b. ensure the patient has a pair of shoes with non-slip soles. c. talk with the patient alone and ask about what caused the bruising d. notify the health care provider so that x-rays can be ordered as soon as possible

c. talk with the patient alone and ask about what caused the bruising

The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching a. a blood test will confirm the presence of abnormal antibodies b. my skin cells will be stained and examined under the microscope c. the rash will be scraped with a razor blade and the flakes cultured d. I will return to have the substances removed and the areas evaluated.

d. I will return to have the substances removed and the areas evaluated.

What is the primary difference between and excoriation and an ulcer a. ulcers do not penetrate below the epidermal junction b. excoriations involve only thinning of the epidermis and dermis c. Excoriations will form crusts or scabs, whereas ulcers remain open d. An excoriation heals without scarring because the dermis is not involved

d. an excoriation heals without scarring because the dermis is not involved.

When performing a physical assessment of the skin, what should the nurse do first a. palpate the temperature of the skin with the fingertips b. assess the degree of turgor by pinching the skin on the forearm c. inspect specific lesions before performing a general examination of the skin. d. ask the patient to undress completely so that all areas of the skin can be inspected

d. ask the patient to undress completely so that all areas of the skin can be inspected.

A patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patients integumentary system. a. warm, flush skin; alopecia, thin nails b. general hyperpigmentation and loss of body hair c. pale skin, pale mucous membranes, hair loss, nail dystrophy d. cold, dry, pale skin. dry coarse hair, brittle, slow growing nails.

d. cold, dry, pale skin. dry coarse hair, brittle, slow growing nails.

When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. 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

d. erythema, e. actinic keratosis

A patient with hypothyroidism has developed carotenemia. The nurse should assess for improvement of this condition on which park of the patients body. a. face b. chest c. sclera d. palms of hands

d. palms of hands

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider a. several dry, scaly patches on the face b. numerous varicosities noted on both legs c. dilation of small blood vessels on the face d. petechiae present on the chest and abdomen

d. petechiae present on the chest and abdomen

An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration a. the skin color over the nose and ears has a blue tint. b. the skin of the extremities is warm and dry touch. c. pressing the skin over the ankles causes pitting for 10 seconds d. pinching the skin under the clavicle causes tenting for 10 seconds

d. pinching the skin under the clavicle causes tenting for 10 seconds

An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne. a. ulcers b. wheals c. vesicles d. pustules

d. pustules

When obtaining important health information from a patient during the assessment of the skin, it is most important for the nurse to ask about. a. a history of freckles as a child b. patterns of weight gain and loss c. communicable childhood illness d. skin problems related to the use of medications

d. skin problems related to the use of medications

During assessment of the patients skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions. a. confluent b. zosteriform c. generalized d. symmetric

d. symmetric

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis. Select all a. patients sclera b. patients nail beds c. soles of the patients feet d. palms of the patients hands e. conjunctiva of the patients eyes

nail beds, conjunctiva of the patients eyes