Med Surg: Chapter 51: Nursing Assessment: Integumentary Function: PREPU

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? A Pustule B Spider angioma C Cyst D Erosion

B

Sudoriferous glands secrete which type of substance? A Hormones B Sweat C Oil D Cerumen

B

A little boy is brought to the school nurse after falling off a swing. The nurse is documenting that the boy has bruising on the lateral aspect of his right arm. What term will the nurse use to describe bruising on the skin in documentation? A Ecchymoses B Telangiectasias C Urticaria D Purpura

A

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high? A Evaporation B Conduction C Convection D Radiation

A

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing? A Lichenification B Keloid C Scales D Atrophy

A

Students are reviewing information about the glands of the skin. The students demonstrate understanding of the material when they state which of the following? A The apocrine glands become active at puberty. B The eccrine glands are primarily located in the axillae. C The sweat glands are responsible for lubricating the hair. D The sebaceous glands are responsible for sweat secretion.

A

The nursing student is learning about the elderly and the instructor is discussing physical changes associated with the aging process. What would the instructor tell the student about common changes in the skin associated with the aging process? A The elderly have skin atrophy. B The elderly have thickened skin. C The elderly have increased hair distribution. D The elderly have decreased xerosis.

A

Which of the following describes a total absence of pigment melanin? A Albinism B Anemia C Vitiligo D Cyanosis

A

Which of the following diagnostics is used to examine cells from herpes zoster? A Tzanck smear B Skin biopsy C Patch testing D Skin scrapings

A

A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum? A prevents drying and cracking of the skin and hair B trapping debris in the external ear C cooling overwarm skin D contributing to acidity of perspiration to decrease microbial growth

A Sebum, which is an oily lubricant, prevents drying and cracking of the skin and hair.

When describing the layers of the skin to a group of nursing students, which of the following would the nursing instructor include as being a component of the dermis? A Fibroblasts B Adipose tissue C Keratin D Melanocytes

A The dermis consists of two layers: the papillary dermis, which is composed primarily of fibroblasts, and the reticular layer, which produces collagen and elastic bundles. The epidermis contains melanocytes and keratin. Adipose tissue is found in the subcutaneous tissue.

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition? A A fungus that enters the skin's surface, causing infection B Irritation of opposing skin surfaces caused by friction C Inflammation of a hair follicle D Spontaneously occurring wheals

B

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? A Epidermis B Dermis C Stratum corneum D Papillary layer

B

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present? A The skin is whitish pink. B The skin is ashen gray and dull. C The skin is dusky blue. D The skin is reddish pink.

B

When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water? A Stratum germinativum B Stratum corneum C Stratum lucidium D Stratum granulosum

B

Which condition is associated with bleeding tendencies or emboli to the skin? A Telangiectasia B Petechiae C Spider angioma D Ecchymosis

B

The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion? A Psoriasis B Port-wine stains C Impetigo D Hives

B A macule is a flat, nonpalpable skin color change (color may be brown, white, tan, purple, red) less than 1 cm with a circumscribed border. Examples include freckles, flat moles, petechia, rubella, vitiligo, port wine stains, and ecchymosis.

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of A albinism. B anemia. C vitiligo. D local arterial insufficiency.

B In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky white spots. Local arterial insufficiency is characterized by marked localized pallor.

Which type of cell is believed to play a significant role in cutaneous immune system reactions? A Phagocytes B Langerhans cells C Melanocytes D Merkel cells

B Langerhans cells are common to the epidermis and are accessory cells of the afferent immune system process. Merkel cells are receptor cells in the epidermis that transmit stimuli to the axons via a chemical response. Melanocytes are special cells of the epidermis that are primarily involved in producing melanin, which colors the hair and skin. Phagocytes are white blood cells that engulf and destroy foreign materials.

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? A Long-standing cardiopulmonary disease B Iron deficiency anemia C Fungal infection D Poor circulation

B The concave shape of the nails, referred to as spooning, is a sign of iron deficiency anemia. Clubbing of the nails, at greater than a 160-degree angle, suggests long-standing cardiopulmonary disease. Nails thicken when there is a fungal infection and poor circulation

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding? A Alopecia B Hirsutism C Jaundice D Hyperpigmentation

B The nurse anticipates finding hirsutism, or excessive hair growth, as Cushing syndrome causes hirsutism, especially in women. Alopecia, jaundice, and hyperpigmentation are not typical assessment findings in clients with Cushing syndrome.

The hemoglobin level should be evaluated for a patient with cyanosis. The nurse is aware that one of the following levels of deoxygenated hemoglobin is considered a symptom of hypoxemia in an adult male with cyanosis. What is the level? A 7 g/100 mL B 5 g/100 mL C 11 g/100 mL D 9 g/100 mL

B When cyanosis occurs, severe hypoxia and hypoxemia already exist. Cyanosis is evident around 5 g/100mL of hemoglobin concentration. Immediate intervention is necessary

A patient has undergone testing in which a clinician has scraped a sample from the patient's skin lesion and fixed the sample to a slide. This patient most likely has which of the following integumentary health problems? A An allergy B A neoplasm C A fungal infection D A viral skin disease

C

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? A Reduction in estrogen production B Reduction in melanin production C Reduction in sebum production D Reduction in the elasticity of the skin

C

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? A Patch B Plaque C Macule D Papule

C

The diagnosis of a skin disorder is made chiefly by which of the following? A Palpation B Biopsy C Visual inspection D Culture

C

The nurse has administered a subcutaneous injection of low-molecular-weight heparin to a patient who is recovering from surgery. This injection will be primarily deposited into: A The dermis B The epidermis C Adipose tissue D Muscle

C

The nurse in an ambulatory care center is admitting an elderly patient who has bright red moles on his skin. Benign changes in elderly skin that appear as bright red moles are termed what? A Solar lentigo B Xanthelasma C Cherry angiomas D Seborrheic keratoses

C

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? A Seborrheic dermatosis B Psoriasis C Herpes zoster D Fungal infection

C

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? A Protect the patient from the light. B Obtain samples of the lesion by scraping. C Make sure that the room is darkened. D Apply a special dye to the area.

C

The nurse's assessment of an older adult patient who is postoperative day 1 following orthopedic surgery reveals scrotal edema. A review of the patient's recent documentation indicates that the patient is likely fluid overloaded. Why are areas such as the scrotum particularly susceptible to edema? A The scrotum lacks an epidermal layer, making it more susceptible to pressure from deeper skin layers. B The scrotum has a thick basement membrane, which is highly vascular. C The vascularity and thin dermis of the scrotum make it prone to edema. D The scrotum has a high concentration of Merkel cells, which are easily engorged with free water.

C

Which diagnostic test is used to examine cells from herpes zoster? A Skin scrapings B Skin biopsy C Tzanck smear D Patch testing

C

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is a symptom of what? A Jaundice B Addison's disease C Vitiligo D Sjorgen's syndrome

C

While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following? A Bright red moles B Hypertrophied scar tissue C Liver spots D Dark discoloration of the skin

C

Which type of heat loss is caused by a cool breeze that blows across the body surface? A Radiation B Conduction C Convection D Evaporation

C Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body. Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? A Sebum deficiency B Dehydration C Fluid retention D Protein deficiency

C Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? A "Have you been in the sun a lot?" B "Have you been diagnosed with Addison's disease?" C "Have you been ingesting large quantities of alcohol?" D "Have you been eating a large amount of carotene-rich foods?"

D

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced? A Convection B Radiation C Evaporation D Conduction

D

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? A Tzanck smear B Skin scraping C Patch test D Biopsy

D

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? A Bright red moles B Liver spots C Dark discoloration of the skin D Yellowish waxy deposits on the eyelids

D

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review? A Arterial blood gases B BUN and creatinine C Glucose level D Hemoglobin and hematocrit

D

When conducting a skin assessment, the nurse notes a purple macular lesion on the client's right upper extremity. The nurse differentiates the lesion as a petechia or ecchymosis based on A size. B exudate. C location. D erythema.

D

Which of the following could be a possible cause of cyanosis? A Carbon monoxide poisoning B Anemia C Fever D Low tissue oxygenation

D

Which of the following is the most common cause of hair loss? A Chemotherapy B Nutritional deficiency C Radiation D Male pattern baldness

D

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? A Protein deficiency B Sebum deficiency C Dehydration D Fluid retention

D Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

sudoriferous glands= ________glands Sebaceous glands= _______ (serum) Endocrine gland secrete _________

Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones.