Chapter 23 - Nursing Assessment: Integumentary System

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding? A. Scar B. Fissure C. Atrophy D. Excoriation

B. Fissure The secondary skin lesion called a fissure is a linear crack or break from the epidermis to the dermis and can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area in which epidermis is missing which exposes dermis (e.g., abrasion or scratch).

Which laboratory test would be most important to check in the patient presenting with purpura? A. Urinalysis B. Serum electrolytes C. Coagulation studies D. White blood cell count

C. Coagulation studies Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore it is most important for the nurse to assess the patient's coagulation studies.

In order to obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use? 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 Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin.

A 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? A. Warm, flushed 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 With hypothyroidism the patient will manifest with cold, dry, pale skin; dry, coarse, brittle hair; and brittle, slow-growing nails. With hyperthyroidism the patient will have warm, flushed skin; alopecia with fine soft hair; and thin nails. With Addison's disease the patient will have loss of body hair and generalized hyperpigmentation, especially in folds. With anemia, the patient will display pallor, pale mucous membranes, hair loss, and nail dystrophy.

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

D. Palms of hands Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet.

A 78-year-old woman 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 to 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. Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool, without edema or central cyanosis.

A 14-year-old female and her mother come to see their nurse practitioner for treatment of the daughter's 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 Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.

The nurse is assessing a white patient's skin color and notices cyanosis. Where on the patient's body would the nurse most likely see this cyanosis? A. Lips B. Legs C. Wrists D. Sclera

A. Lips On light-skinned individuals, cyanosis or grayish blue tone initially appears in lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet.

The nurse performs a physical assessment on a dark-skinned African American man 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 Cyanosis will appear ashen or gray color and is most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds of dark-skinned individuals. The nail beds, earlobes, lips, mucous membranes, and palms and soles of feet would be appropriate locations to assess for cyanosis in a light-skinned individual.

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. What term will the nurse use to describe this skin abnormality? A. Petechiae B. Erythema C. Ecchymosis D. Telangiectasia

A. Petechiae Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

During 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? 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 Petechiae present as tiny, purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

A nurse is obtaining a health history from a 56-year-old man who has a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient? 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?" A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

Inspection of an obese, female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What should the nurse suspect that 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 Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising. An unusual odor would not normally be attributed to age-related changes or skin atrophy.

Which medication is most likely to have an effect on the patient's integumentary system? A. Diuretic B. Corticosteroid C. Benzodiazepine D. Calcium channel blocker

B. Corticosteroid Corticosteroids can have unwanted integumentary side effects such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.

The patient has diffuse distribution of moles on her body. A biopsy of one on her back will be done to assess for malignancy. What does the nurse know as the rationale for doing a punch biopsy? 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. The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide.

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)? A. Patient's sclera B. Patient's nail beds C. Soles of the patient's feet D. Palms of the patient's hands E. Conjunctiva of the patient's eyes

B. Patient's nail beds E. Conjunctiva of the patient's eyes In patients with darkly pigmented skin, the conjunctiva and nail beds are often examined to assess for cyanosis. Palms of the hands, soles of the feet, and the sclera are not the focus when assessing for cyanosis.

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. What normal changes of aging does the nurse know occur that 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 normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

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." A patch test is used to determine skin reactions to certain allergens applied to the skin. The patient will return in 48 to 72 hours for allergen removal and return again in 96 hours for evaluation.