Chapter 51: PrepU - Nursing Assessment: Integumentary Function

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? 1- Vesicles 2- Bullae 3- Cysts 4- Pustules

1

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? 1- Jaundice 2- Pallor 3- Bronzed appearance 4- Cherry red face

1

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? 1- Freckles 2- Dryness 3- Itchy spots 4- Yellowish waxy deposits

1

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? 1- Reduction in sebum production 2- Reduction in the elasticity of the skin 3- Reduction in melanin production 4- Reduction in estrogen production

1

Contact with a pathogen has precipitated a cutaneous immune reaction on a nurse's hands. The nurse would understand that this reaction primarily involves the action of what component of the integumentary system? 1- Langerhans cells 2- Merkel cells 3- Basement membrane 4- Melanocytes

1

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? 1- Iron deficiency anemia 2- Long-standing cardiopulmonary disease 3- Fungal infection 4- Poor circulation

1

Petechiae are associated with which of the following disorders? 1- Thrombocytopenia 2- Deep vein thrombosis 3- Pulmonary emboli 4- Acute respiratory distress syndrome (ARDS)

1

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? 1- Cherry angiomas 2- Solar lentigo 3- Seborrheic keratoses 4- Xanthelasma

1

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? 1- Conduction 2- Convection 3- Evaporation 4- Radiation

1

The nurse is teaching health promotion to a class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they identify that clients need how much sun exposure to synthesize sufficient vitamin D? 1- 5 to 30 minutes twice a week 2- 30 to 60 minutes weekly 3- 60 to 90 minutes weekly 4- 90 to 120 minutes twice a week

1

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? 1- Liver spots 2- Dark discoloration of the skin 3- Bright red moles 4- Hypertrophied scar tissue

1

A nurse is assessing a patient with impetigo. The nurse would most likely observe which of the following? 1- Wheal 2- Pustule 3- Vesicle 4- Papule

2

The nurse is assessing an African American client and notes a streak of pigmentation in the client's fingernails. The nurse determines that this finding indicates 1- chronic anemia. 2- normal variation. 3- melanoma. 4- smoker's fingernails.

2

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? 1- Fungal infection 2- Herpes zoster 3- Psoriasis 4- Seborrheic dermatosis

2

The nurse is caring for an adult patient with a normal body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient? 1- 250 mL/day 2- 600 mL/day 3- 800 mL/day 4- 1,000 mL/day

2

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? 1- Erosion 2- Pustule 3- Cyst 4- Spider angioma

4

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: 1- The epidermis 2- The dermis 3- Muscle 4- Adipose tissue

4

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? 1- Flat with skin color change 2- Circumscribed border 3- Greater than 1 cm in diameter 4- Elevated and palpable

4

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease? 1- Telangiectasia 2- Ecchymosis 3- Fluid-filled vesicles 4- Purplish cutaneous lesions

4

When assessing a patient's skin, the nurse would use palpation to assess which of the following? 1- Color 2- Moisture 3- Texture 4- Turgor

4

When evaluating fluid balance in a patient with a fever, the nurse estimates insensible fluid loss. A loss of 1,000 mL/24 hours can occur with a temperature of: 1- 100°F. 2- 101°F. 3- 102°F. 4- 103.5°F.

4

Which of the following could be a possible cause of cyanosis? 1- Carbon monoxide poisoning 2- Fever 3- Anemia 4- Low tissue oxygenation

4

Which of the following pigments influences hair color? 1- Pheromones 2- Keratin 3- Sebum 4- Melanin

4

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is: 1- Cyanosis 2- Addison's disease 3- Polycythemia 4- Vitiligo

4

While performing perineal care for a female patient who has been recently admitted to the hospital, the nurse notes that the patient's pattern of pubic hair growth is more characteristic of a male's pattern of hair growth. The nurse should know that this could possibly be attributed to: 1- A fungal infection of the pubic hair follicles 2- Chronic urinary incontinence 3- A genitourinary disorder 4- An endocrine disorder

4

The nurse notes red, papular, round lesions on the client's back that blanch with light pressure. Which is the appropriate action by the nurse? 1- Notify the physician. 2- Document the finding. 3- Apply barrier cream. 4- Turn and reposition the client.

2

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as 1- spider angioma. 2- petechiae. 3- ecchymosis. 4- telangiectasia.

2

Which factor causes wrinkles among older adults? 1- Decrease in melanin 2- Loss of subcutaneous tissue 3- Decrease in estrogen production 4- Decrease in sebum

2

Which secondary skin lesions are associated with eczema? 1- Scales 2- Crusts 3- Ulcers 4- Erosion

2

Which term describes the transfer of heat from the body to a cooler object in contact with it? 1- Radiation 2- Conduction 3- Lichenification 4- Evaporation

2

Which type of cell is believed to play a significant role in cutaneous immune system reactions? 1- Merkel cells 2- Langerhans cells 3- Melanocytes 4- Phagocytes

2

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? 1- Concave 2- Brittle 3- Discolored 4- Clubbing

4

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? 1- Skin scraping 2- Tzanck smear 3- Patch test 4- Biopsy

4

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? 1- Liver spots 2- Dark discoloration of the skin 3- Bright red moles 4- Yellowish waxy deposits on the eyelids

4

The epidermis consists of four layers as listed below. Place the layers in the proper order from outermost to innermost.

Stratum corneum Stratum lucidium Stratum granulosum Stratum germinativum

Nursing students are reviewing information about the skin structure. The students demonstrate understanding of the material when they identify which of the following as being found in the epidermis? Select all that apply. 1- Merkel cells 2- Langerhan cells 3- Blood vessels 4- Melanocytes 5- Sweat glands

1,2,4

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? 1- prevents drying and cracking of the skin and hair 2- cooling overwarm skin 3- trapping debris in the external ear 4- contributing to acidity of perspiration to decrease microbial growth

1

A 29-year-old woman who gave birth to her first child yesterday had a particularly long labor but vaginally delivered a healthy infant. The nurse notes during this morning's assessment that the woman now has petechiae on her face. The nurse should understand that these lesions are a result of what process? 1- Broken blood capillaries 2- Hormonal changes 3- Inflammation 4- A temporary autoimmune response

1

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? 1- Scale 2- Crust 3- Ulcer 4- Scar

1

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? 1- Bronze 2- Yellow 3- Gray 4- Orange-green

1

A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas? 1- Sclerae 2- Mucous membranes 3- Nail beds 4- Ear lobes

1

The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of? 1- Psoriasis 2- Vitiligo 3- Diabetes 4- Melanoma

1

Nursing students are reviewing information about primary and secondary lesions. The students demonstrate understanding of the information when they identify which of the following as a primary lesion? 1- Ulcer 2- Fissure 3- Wheal 4- Keloid

3

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? 1- The skin is ashen gray and dull. 2- The skin is dusky blue. 3- The skin is reddish pink. 4- The skin is whitish pink.

1

The nurse is tabulating a patient's 24-hour fluid balance and is aware that insensible perspiration cannot be accurately measured or documented. The nurse should be aware that a normal adult typically loses how much water in this way each day? 1- 600 mL 2- 750 mL 3- 900 mL 4- 1 L

1

Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate? 1- Thighs 2- Eyebrows 3- Beard 4- Axillae

3

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? 1- Hives 2- Impetigo 3- Port-wine stains 4- Psoriasis

3

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? 1- Apply a special dye to the area. 2- Make sure that the room is darkened. 3- Protect the patient from the light. 4- Obtain samples of the lesion by scraping.

3

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of 1- albinism. 2- vitiligo. 3- anemia. 4- local arterial insufficiency.

3

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? 1- Petechiae 2- Ecchymoses 3- Cherry angiomas 4- Telangiectasias

1

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review? 1- Hemoglobin and hematocrit 2- Arterial blood gases 3- BUN and creatinine 4- Glucose level

1

Three female students share an apartment. They notice after several months that their menstrual cycles are coordinating. What is speculated to be responsible for the synchronization of their monthly cycles? 1- apocrine secretions 2- eccrine secretions 3- sebaceous secretions 4- pheromone secretions

1

To detect cyanosis in clients with dark skin, the nurse should assess which area? 1- Oral mucosa 2- Fingernails 3- Sclera 4- Nose

1

What body structures have keratin as part of their composition? 1- All options are correct. 2- fingernails 3- hair 4- skin

1

Which cells play a role in cutaneous immune system reactions? 1- Langerhans' cells 2- Merkel cells 3- Melanocytes 4- T-lymphocytes

1

Which of the following diagnostics is used to examine cells from herpes zoster? 1- Tzanck smear 2- Skin scrapings 3- Patch testing 4- Skin biopsy

1

Which of the following is the most common cause of hair loss? 1- Male pattern baldness 2- Nutritional deficiency 3- Chemotherapy 4- Radiation

1

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following? 1- Keloid 2- Lichenification 3- Nodule 4- Cicatrix

1

A nurse is conducting a comprehensive assessment of an elderly man who has been admitted to the geriatric medical unit with dehydration and suspected malnutrition. The nurse's examination of the patient's integumentary system reveals several notable findings. Which of the following findings most clearly warrants medical follow-up? 1- The patient has an irregularly shaped mole on his scalp that has been growing in recent months 2- There is dark discoloration of the skin on the patient's shins and ankles and the skin has a shiny appearance. 3- There is a yellowish waxy deposit on the patient's upper and lower eyelids. 4- The patient has numerous superficial red marks on the skin of his forearms and the backs of his hands.

1

The nurse is having difficulty seeing a client's rash. Which action(s) should the nurse perform to facilitate the assessment? Select all that apply. 1- Stretch the skin gently. 2- Point a penlight laterally across the affected part. 3- Pull the skin downward. 4- Apply an emollient.

1,2

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply. 1- Wound size 2- Periwound skin 3- Wound bed 4- Pattern of eruption

1,2,3

Certain medications are photosensitizing and increase the skin damage that results from sun exposure in the elderly. Therefore, a history of medication use is part of assessing age-related conditions of the skin. Which of the following medications are known to be photosensitizing? Select all that apply. 1- Antihistamines 2- Antibiotics 3- Antihypertensives 4- Diuretics

1,2,4

A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment? 1- Purplish tinge to the hands 2- Cherry red color to the nail beds, lips, and oral mucosa 3- Dull or yellow-brown shade to his chest 4- Ashen gray and dull color to his face

2

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? 1- Telangiectasias 2- Ecchymoses 3- Purpura 4- Urticaria

2

A nurse in the intensive care unit is closely monitoring the fluid balance of an acutely ill patient. The nurse is aware that insensible water loss from the epidermis occurs constantly. What characteristic of the stratum corneum of the epidermis limits epidermal water loss? 1- The presence of semipermeable membranes in epidermal skin cells 2- The presence of lipids in the stratum corneum 3- The inability to selectively sequester water in the cells of the stratum corneum 4- The hypertonic intracellular environment in cells of the stratum corneum

2

A nurse is preparing a presentation for a local senior citizen group about skin care and changes that occur with aging. The nurse plans to include measures to reduce the risk of minor trauma based on the understanding about which of the following? 1- The loss of melanin makes the skin more vulnerable to injury. 2- The thining of epidermal-dermal junction promotes shearing. 3- Loss of subcutaneous tissue dimishes protection of underlying tissues. 4- Sebum secretion decreases resulting in more fragile skin.

2

A nurse's assessment of a newly admitted patient is remarkable for an area of erythema on the patient's upper thigh. The nurse is aware that erythema is the physiological result of: 1- Decreased oxygen saturation 2- Dilation and congestion of capillaries 3- The initiation of the clotting cascade 4- The presence of blood in the interstitial space

2

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? 1- Atrophy 2- Lichenification 3- Keloid 4- Scales

2

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? 1- Anemia 2- Hypoxia 3- Local trauma 4- Psoriasis

2

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? 1- Epidermis 2- Dermis 3- Papillary layer 4- Stratum corneum

2

An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned that he has melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of? 1- Senile keratoses 2- Senile lentigines 3- Melanoma 4- Freckles

2

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? 1- Splinter hemorrhage 2- Beau's line 3- Paronychia 4- Clubbing

2

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion. 1- Macule 2- Vesicle 3- Pustule 4- Cyst

2

Production of melanin is controlled by a hormone secreted by which gland? 1- Thyroid 2- Hypothalamus 3- Adrenal 4- Parathyroid

2

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? 1- Vitiligo 2- Psoriasis 3- Melanoma 4- Petechia

2

A client comes to the clinic for evaluation of several lesions which are suspected to be fungal in origin. To confirm the diagnosis, the nurse would prepare the client for which evaluation? 1- skin biopsy 2- patch testing 3- skin scrapings 4- clinical photography

3

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? 1- Macule 2- Vesicle 3- Pustule 4- Cyst

3

A nurse provides care in a large, urban hospital that serves a clientele of many different ethnicities and racial backgrounds. Which of the following statements is accurate regarding a patient's integumentary health? 1- Patients with darker skin have skin that is generally more resilient than that of lighter-skinned patients. 2- Patients with darker skin are largely immune to ultraviolet damage but have an increased risk of skin infections. 3- Patients with darker skin and patients with lighter skin have similar risks of most skin diseases. 4- Patients with darker skin have higher incidence of most skin disorders, but these are usually more difficult to diagnose.

3

A patient dropped a heavy flower pot on his foot. He broke his big toe and damaged the keratin layer on his toenail, which fell off weeks later. The nurse recorded the date when the nail fell off and advised the patient that his toenail should be completely renewed within: 1- 3 months. 2- 6 months. 3- 1 year. 4- 2 years.

3

During assessment of a light-skinned patient, the nurse notices a yellow color present in the sclera of both eyes and the mucous membranes. The nurse knows that this finding could be associated with the presence of: 1- Uremia. 2- Addison's disease. 3- Liver dysfunction. 4- Carotenemia.

3

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? 1- The scrotum has a high concentration of Merkel cells, which are easily engorged with free water. 2- The scrotum lacks an epidermal layer, making it more susceptible to pressure from deeper skin layers. 3- The vascularity and thin dermis of the scrotum make it prone to edema. 4- The scrotum has a thick basement membrane, which is highly vascular.

3

Which of the following observations helps the nurse in determining adequate oxygenation? 1- Appearance of lunula 2- Hard keratin 3- Pink nail beds 4- Capillary refill time

3

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? 1- Spontaneously occurring wheals 2- A fungus that enters the skin's surface, causing infection 3- Inflammation of a hair follicle 4- Irritation of opposing skin surfaces caused by friction

4

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? 1- Convection 2- Conduction 3- Radiation 4- Evaporation

4

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule? 1- Skin biopsy 2- Skin scrapings 3- Tzanck smear 4- Patch test

4

The nurse is assessing the skin of an older adult patient. Which of the following would the nurse identify as abnormal? 1- Cherry angioma 2- Telangiectasias 3- Xerosis 4- Bulla

4