Chapter 22, Nursing Assessment: Integumentary System: Integ Assessment

During the change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, what should the incoming nurse expect to find? Tiny, purple spots on the skin Large ecchymotic areas on the skin Hyperkeratotic papules and plaques Small, raised red areas on the soles of the feet

Tiny, purple spots on the skin

The nurse assessed the patient's skin lesions as circumscribed, with a superficial collection of serous fluid, and less than 0.5 cm in diameter. What term describes these lesions? Wheals Papules Pustules Vesicles

Vesicles

The nurse is caring for a patient with a superficial lesion. Which biopsy is best suited for this patient? Shave biopsy Punch biopsy Incisional biopsy Excisional biopsy

Shave biopsy

A patient had an infection underneath the toenail, and the entire nail was removed. The patient asks the nurse how long it will take the toenail to grow back to its normal size. What should be the nurse's answer? 1-2 months 3-6 months 6-12 months 12-24 months

12-24 months

The patient has been snacking on carrots each day and has developed carotenemia. The nurse knows that improvement in this condition will be most evident on which part of the patient's body? Face Chest Sclera Palms of hands

Palms of the hands

The nurse is assessing a patient who has dark skin for cyanosis. What assessment findings would indicate cyanosis in individuals with dark skin? Reddish skin tone Deeper brown or purple skin tone Grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, palms, and soles Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds

Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds

When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. Fissure Dry skin Wrinkling Excoriation Decreased turgor

Dry skin Wrinkling Decreased turgor

When performing a skin assessment on a patient, which principles should the nurse follow? Select all that apply. Be systematic and proceed from head to toe. Use the metric system when taking measurements. Ensure the patient is wearing a comfortable dress. Have a private examination room with a moderate temperature. Perform a lesion-specific examination followed by a general inspection.

Be systematic and proceed from head to toe. Use the metric system when taking measurements. Have a private examination room with a moderate temperature.

A nurse is obtaining a sample for an indirect immunofluorescence test for a patient suspected of having systemic lupus erythematosus (SLE). Which type of sample does the nurse expect to collect? Blood Throat swab Punch biopsy specimen of the skin Shave biopsy specimen of the skin

Blood

To determine the presence of petechiae in a patient with dark skin, the nurse should assess what part of the body? Nail Face Buttocks Conjunctiva

Conjunctiva

A 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? Warm, flushed skin, alopecia, and thin nails General hyperpigmentation and loss of body hair Pale skin, pale mucous membranes, hair loss, and nail dystrophy Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails

Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails

A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply. Decrease in the production of melanin Increase in the production of melanin Increase in the number of melanocytes Decrease in the number of melanocytes Decreased exposure to sun in old age

Decrease in the production of melanin Decrease in the number of melanocytes

A nurse is discussing the health changes associated with aging with a group of older adults in a community clinic. One of the members of the group asks about dry skin and aging. The nurse explains that, in the elderly population, dry skin comes with aging due to what? Select all that apply. Decreased production of sebum. Decreased immunocompetence. Decreased subcutaneous fat tissue. Decreased blood supply to the skin. Decreased water content in the body.

Decreased production of sebum. Decreased water content in the body.

During an initial assessment of an obese female patient, what specific question should the nurse ask to determine the metabolic pattern related to her skin? Is your sleep being disturbed by any skin condition? Is there any specific food that also causes a skin allergy? Do you have any chafing or a rash in areas where skin overlaps? Are there any skin changes during exercise or other activities?

Do you have any chafing or a rash in areas where skin overlaps?

A nurse is performing a skin assessment on a female patient. The patient has excessive hair on the chest and the face. The nurse expects that what test will be performed? Skin biopsy Estrogen test Thyroid function test Blood test to determine clotting time

Estrogen test

A nurse is assessing a patient who has yellow skin and nails. Which chemical or pigment abnormality does the nurse expect the patient to have? Excess melanin Excess carotenes Excess oxyhemoglobin Excess deoxyhemoglobin

Excess carotenes

A nurse is performing skin assessment on a patient. The patient is obese and a security guard by profession. The patient's skin on the sole of the feet is extremely hard and thick. What is the most likely cause for this finding? Injury to the sole Diminished blood supply to the feet Excessive pressure due to weight bearing Infection of the feet causing lesions in the soles

Excessive pressure due to weight bearing

A patient has been administered a patch test to determine the patient's allergy to rubber. What is an important nursing intervention for this patient? Keep the patient in the health care facility for close observation. Instruct the patient to return in 48 to 72 hours for removal of allergens. Teach the patient how to administer an epinephrine injection, if required. Instruct the patient to come back after a week for a preliminary evaluation.

Instruct the patient to return in 48 to 72 hours for removal of allergens.

A patient with a long history of sun exposure has been diagnosed with skin cancer. The nurse recognizes that chronic exposure to ultraviolet (UV) rays has what effects on the skin that increase the risk for skin cancer? Select all that apply. It increases blood flow to the skin. It increases the rate of cell multiplication. It decreases the water content of the skin. It causes degeneration of elastic fibers in skin tissue. It decreases the skin's ability to repair cellular damage.

It increases the rate of cell multiplication. It decreases the skin's ability to repair cellular damage.

A patient is scheduled for a Wood's lamp test. What is the most appropriate way for the nurse to prepare the room? Keep the room dark. Soundproof the room. Keep the room well lit. Keep an infrared lamp in the room.

Keep the room dark.

When assessing a 73-year-old female patient, the nurse found wrinkles, sagging breasts, and tenting of the skin, gray hair, and thick, brittle toenails. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system? Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

When jaundice is suspected in a patient, which areas should the nurse check for skin color? Select all that apply. Tongue Nail beds Earlobes Conjunctiva Buccal mucosa

Nail beds Conjunctiva Buccal mucosa

A nurse is teaching a group of nursing students about the perception of cold in obese people. Which statement should be included in the education? Obese people have fewer cold receptors. Obese people have better fat insulation. Obese people have better cold tolerance. Obese people have an abnormal hypothalamic functioning.

Obese people have better fat insulation.

The nurse is caring for a patient with dark skin. The nurse suspects that the patient might have jaundice. Which areas should the nurse check to confirm the physical manifestations of jaundice? Select all that apply. Fingernails Oral mucosa Color of the skin Soles and palms Sclera of the eye

Oral mucosa Soles and palms Sclera of the eye

When assessing the patient's integumentary system, which dermatologic manifestations may indicate systemic problems? Select all that apply. Pallor Jaundice Skin tags Cyanosis Cherry angiomas

Pallor Jaundice Cyanosis

To obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use? Inspection of skin color Examination for vascularity Palpation of skin with the hand Percussion of the skin on the back

Palpation of skin with the hand

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 that apply. Patient's sclera Patient's nail beds Soles of the patient's feet Palms of the patient's hands Conjunctiva of the patient's eyes

Patient's nail beds Conjunctiva of the patient's eyes

A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. Which term best describes these findings? Purpura Petechiae Hematoma Ecchymosis

Petechiae

A nurse is assessing a male client who reports small papules and pustules in the beard area. The papules started appearing after he shaved his beard the previous day. Based on this information, what is the most likely patient diagnosis? Acne Moles Comedo Pseudofolliculitis

Pseudofolliculitis

A 14-year-old girl and her mother come to see the nurse practitioner for treatment of the daughter's acne. For what should the nurse assess the patient to show the existence of acne? Ulcers Wheals Vesicles Pustules

Pustules

Which process should a nurse follow when obtaining a wound culture from a surgical site? Rolling a sterile swab from the center of the wound outward Using a sterile swab, starting on the outer edge of the wound Thoroughly irrigating the wound before collecting the culture Using a sterile swab to wipe the crusted area around the outside of the wound

Rolling a sterile swab from the center of the wound outward

A nurse is giving a lecture on nutrition to a group of nursing interns. The nurse says that sunlight is the best source of vitamin D. Based on their previous knowledge, what would be the most appropriate interpretation of this statement by the interns? Sunlight stimulates the production of vitamin D in the body. Sunlight contains vitamin D, which is easily absorbed by the skin. Exposure to sunlight increases craving for foods rich in vitamin D. Sunlight causes proliferation of the cells containing vitamin D precursors.

Sunlight stimulates the production of vitamin D in the body.

On inspection of a patient's skin, the nurse notes dilated, superficial, cutaneous small blood vessels on the patient's face. What is this assessment finding called? Vitiligo Intertrigo Petechiae Telangiectasia

Telangiectasia

While performing a capillary refill test, the nurse observes that a patient's nail beds become blanched and remain discolored even when the pressure on the nail beds is released. What can the nurse interpret from this finding? The findings are normal. Jaundice may be present. The patient may have a thyroid disorder. The patient may have subcutaneous bleeding.

The patient may have subcutaneous bleeding.

A nurse educator explains to a group of nursing students why skin becomes darker in color when exposed to sunlight. Which statement by a student indicates the teaching has been understood? "The rays from the sun stimulate the production of melanin, giving a tan to the skin." "The rays from the sun inhibit the production of melanin, causing the skin to darken." "The rays from the sun burn the outer layer of the skin, making the skin dark and painful." "The rays from the sun cause increased blood flow to the skin, giving a dark red color to the skin."

"The rays from the sun stimulate the production of melanin, giving a tan to the skin."

Which of these techniques are appropriate when the nurse is performing a physical examination of a patient's skin? Select all that apply. Assessing for skin color changes. Using a flashlight in a poorly lit room. Pressing on a lesion to check for blanching. Checking skin temperature by palpating with the palm of the hand. Performing a lesion-specific examination first and then a general inspection.

Assessing for skin color changes. Pressing on a lesion to check for blanching.

A nurse asks a nursing student to determine the skin color of a patient whose skin is tanned in the exposed areas. Where is the best place on a patient's body to accurately determine skin color? Face Palms Buttocks Nail beds

Buttocks

When assessing a dark-skinned patient, the nurse finds that there are dark longitudinal bands in the patient's nail beds. What is the most likely interpretation of this finding? The patient may have psoriasis. It is a normal finding in this patient. Anemia may be present in this patient. The patient may have a thyroid disorder.

It is a normal finding in this patient.

The patient has diffuse distribution of moles on the body. A biopsy of one on the patient's back will be done to assess for malignancy. The nurse knows that what is the rationale for doing a punch biopsy? It is used for a superficial lesion. It provides a full-thickness of skin. It is used for good cosmetic results. It is used because the lesion is too large to remove.

It provides a full-thickness of skin.

When assessing the cognitive-perceptual pattern in relation to the skin, the nurse questions the patient regarding which of these? Joint pain Changes in sleep habits Recent changes in wound healing Self-care habits related to daily hygiene

Joint pain

The nurse is assessing an older patient. When assessing the hair and nails, the nurse will recognize that age-related changes in the hair and nails include which of these? Select all that apply. Thicker hair Scaly scalp Thinner nails Longitudinal ridging on nails Prolonged blood return when nails are blanched

Scaly scalp Longitudinal ridging on nails Prolonged blood return when nails are blanched

A nurse is assessing a patient with psoriasis. The nurse explains the pathology of psoriasis, stating that it occurs due to abnormal changes in the cell cycle of the skin layers. Which change in the cell cycle is the nurse referring to? The outer dead layer of skin cells is not shed. The inner layer of skin stops producing new skin cells. The rate of removal of outer dead skin is much more than the rate of production of new skin cells. The rate of new skin cell production is much more than the rate of removal of outer dead skin cells.

The rate of new skin cell production is much more than the rate of removal of outer dead skin cells.

A nurse educator is teaching a group of nursing students about skin assessments. The nurse asks the students the reason for assessment of cyanosis, pallor, and jaundice in the nail beds, sclera, and lips. What is the most appropriate response by the students? These areas have the least pigmentation. These areas have the highest blood flow. These areas are rich in sensory receptors. These areas are the most accessible to a nurse.

These areas have the least pigmentation.

A nurse scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture? To identify an allergen To identify a fungal infection To identify a viral infection To identify a bacterial infection

To identify a fungal infection

While explaining the structure of the skin to a patient, the nurse says that the outermost layer of the skin consists mainly of dead cells. The patient asks the nurse, "Why do our bodies need these dead cells?" What is the most appropriate answer for the nurse to give? To protect the viable cells underneath To preserve water for the viable cells underneath To provide nutrition to the viable cells underneath To provide antiseptic properties that prevent infection in the body

To protect the viable cells underneath

The nurse is teaching a patient about the skin's ability to synthesize vitamin D when exposed to sunlight. Which instructions should the nurse include? Select all that apply. Vitamin D is synthesized by the action of ultraviolet (UV) light. The papillary layer helps in activating the precursors to vitamin D. Ultraviolet rays act on vitamin D precursors present in the epidermis. The reticular layer of the dermis plays an important role in vitamin D synthesis. Endogenous synthesis of vitamin D is critical for calcium and phosphorus balance.

Vitamin D is synthesized by the action of ultraviolet (UV) light. Ultraviolet rays act on vitamin D precursors present in the epidermis. Endogenous synthesis of vitamin D is critical for calcium and phosphorus balance

A nurse is assessing a patient with chalky, white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis? Keloid Vitiligo Intertrigo Hypopigmentation

Vitiligo

A nurse is dressing the wound of a patient whose fingers were injured in an accident. One of the fingernails is missing. The patient asks the nurse about when the fingernail will grow back. What is the most appropriate answer? Within 3 months Within 6 months Within 12 months Within 15 months

Within 6 months