MED SURG 2 CH. 22// EXAM 5

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

A dark-skinned patient has been admitted to the hospital with chronic heart 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.

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to 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. 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

A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Bathe with antibacterial soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover affected area with snug fitting clothing. E. Allow lesions to dry before applying topical medication.

A, C, E

A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. Which of the following client statements indicates a need for further teaching? A. "I can expect redness around the site for 3 days." B. "I will call my doctor if I have a fever." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 7 days for removal of my sutures."

A. "I can expect redness around the site for 3 days."

The patient is visiting the free clinic to refill her medication. During the generalized assessment, the nurse documents alopecia; and increased heart rate; warm, moist, flushed skin; and then 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 healthcare provider? A. Hyperthyroidism B. Systemic lupus erythematosus C. Vitamin B1 (thiamine) deficiency D. Human immunodeficiency virus (HIV) infection

A. Hyperthyroidism

A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply.) A. Scrape the site with a wooden tongue depressor. B. Puncture the crusted area with a sterile needle. C. Swab the crusted area with a sterile cotton-tipped applicator. D. Place cotton-tipped applicator in culturette tube. E. Place culturette tube in ice.

B, D, E

Age-related changes in the hair and nails include (select all that apply) a. oily scalp. b. scaly scalp. c. thinner nails. d. thicker, brittle nails. e. longitudinal nail ridging.

B, D, E

A nurse is providing teaching to a client about a new prescription for clotrimazole (Lotrimin). Which ofthe following should the nurse include in the teaching? A. "It reduces the discomfort of a herpetic infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks after the fungal lesions are gone." D. "Allow the area to remain moist before applying."

C. "Apply the topical medication for up to 2 weeks after the fungal lesions are gone."

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.

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, E

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.

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

Diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained. b. a more definitive diagnosis is needed. c. percussion reveals an abnormal finding. d. treatment with prescribed medication has failed.

b. a more definitive diagnosis is needed.

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks 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.

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

b. intradermal bleeding.

The primary function of the skin is a. insulation. b. protection. c. sensation. d. absorption.

b. protection.

During the physical examination of a patient's skin, the nurse would a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c. pinch up a fold of skin to assess for turgor.

When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding a. joint pain. b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c. recent changes in wound healing.

When documenting normal findings of an assessment of the patient's skin, which entry by the nurse is most appropriate? a."Skin warm and dry; turgor good; nails flat and pink; old surgical scars noted on abdomen." b."History of allergic rashes, skin very fair with numerous freckles, warm and intact; no lesions noted." c."Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems with skin." d."No history of skin problems; skin intact, pink, temperature cooler in extremities; no lesions except numerous brown moles."

c."Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems with skin."

What is the primary difference between an 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.

Priority Decision: 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 all areas of the skin can be inspected.

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

Persons with dark skin are more likely to develop a. keloids. b. wrinkles. c. skin rashes. d. skin cancer

a. keloids.

To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is a. palpation. b. inspection. c. percussion. d. auscultation.

a. palpation.

A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate reviewing to confirm this diagnosis? A. Potassium hydroxide (KOH) B. Culture and sensitivity C. Tzanck smear report D. Biopsy

C. Tzanck smear report

When examining the skin of an 80-year-old patient, the presence of which lesions will be of most concern to the nurse? A.Varicosities B.Cherry angiomas C.Actinic keratoses D. Seborrheic keratoses

C.Actinic keratoses

What is the most common diagnostic test used to determine a causative agent of skin infections? a. Culture b. Tzanck test c. Immunofluorescent studies d. Potassium hydroxide (KOH) slides

a. Culture

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 this patient. b. What is the distribution terminology for these lesions? c. What additional information does the nurse need to document the critical components of these lesions?

a. Identify the type of primary skin lesion described by this patient.

The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals. b. papules. c. pustules. d. plaques.

a. wheals.

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo

b. Fissure

A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient 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

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.

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 hemorrhages

b. Small, superficial, dilated blood vessels

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 adult, which factor is likely to contribute to dry skin? a. Increased bruising b. Excess perspiration c. Decreased extracellular fluid d. Decreased peripheral blood supply

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

On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c. Nevus of Ota.

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.

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

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

When obtaining important health information from a patient during assessment of the skin, it is 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 illnesses. d. skin problems related to the use of medications.

d. skin problems related to the use of medications.