Integumentary Assessment/Problems
The nurse is preparing to reexamine the skin of a patient who has a history of malignant skin growths. Which preparation by the nurse is incorrect? 1. Allow the patient to leave on underwear and socks. 2. Plan to use the techniques of inspection and palpation. 3. Include the hair, nails, scalp, and mucous membranes. 4. Explain the need for a penlight and magnifying glass.
ANS: 1 The patient needs to completely undress for a thorough inspection, especially with a history of malignant skin growths.
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin c. Dryness and scaling in the area b. Alopecia of the affected areas d. Reddish-brown skin discoloration
ANS: A Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring.
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.
ANS: B Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease.
A 35-yr-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 contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face
ANS: B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control.
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned and has blue eyes. d. The patient's mother died of a malignant melanoma.
ANS: B Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor.
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair
ANS: B Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes.
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
ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently.
During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent c. Zosteriform b. Symmetric d. Generalize
ANS: B The description of the lesions indicates that they are grouped in a bilateral distribution. The other terms are inconsistent with the description of the lesions
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 c. Incisional biopsy b. Punch biopsy d. Excisional biopsy
ANS: C An incisional biopsy would remove the entire mole and the tissue borders.
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse 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
ANS: C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes.
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Notify the health care provider so that radiographs can be ordered.
ANS: C The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution.
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.
ANS: D The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts.
The nurse is developing a health promotion plan for an older adult who 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
ANS: D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure.
The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding causes the nurse the most concern? 1. Edema formation 2. Dry, macerated skin 3. Increased lesion oozing 4. Excessive skin oiliness
ANS: 2 Edema is not a common reaction to wet dressings. Wet dressings should not be prescribed for more than 72 hours, because the skin may become too dry or macerated.
The nurse in a health care provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin? 1. Detection of skin cancer early can improve chances of a cure. 2. The skin is a good communicator regarding the patient's health. 3. Skin lesions are seen as solid predictors of general health state. 4. The patient's psychological health is
ANS: 2 Skin cancer can be detected early with regular skin inspections; however, the nurse's focus on changes is not just related to skin cancer.
A patient presents with skin lesions that appear reddened, with seeping areas partially crusted over. The HCP orders a viral culture to be performed. Which action by the nurse is inappropriate when collecting the culture specimen? 1. An intact vesicle is gently squeezed to obtain fluid. 2. A sterile cotton swab is used to acquire culture material. 3. The collected fluid is evenly distributed over a glass slide. 4. The specimen is immediately transported to the laboratory
ANS: 3 If an intact vesicle is available, it is gently squeezed to obtain fluid. If the area is crusted over, the crusts are removed or punctured to obtain culture fluid.
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.
ANS: A Because the appearance of the lesion is suggestive of actinic keratosis or possible squamous cell carcinoma, the appropriate treatment would be excision and biopsy
The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.
ANS: A The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal.
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or compresses can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.
ANS: A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.
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. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.
ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require registered nurse (RN) level education and scope of practice.
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Papular, wheal-like lesions with white deposits on the hair shaft c. Patchy areas of alopecia with small vesicles and excoriated areas d. Red, hivelike papules and plaques with sharply circumscribed borde
ANS: B Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low dose systemic chemotherapy is used to treat BCC
ANS: C BCC is frequently associated with sun exposure, and preventive measures should be taken for future sun exposure.
What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.
ANS: C Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems.
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient uses bacitracin-neomycin-polymyxin on minor abrasions. d. The patient takes diphenhydramine at night if persistent itching occurs.
ANS: C Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient.
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face
ANS: C Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies.
Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection
ANS: C Warm water and moisturizing soap will avoid overdrying the skin.
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 c. Cotton-tipped applicators b. Patch test instruments d. Syringe and intradermal needle
ANS: C Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators.
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.
ANS: D The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it.
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap
ANS: D Cleaning the skin is within the education and scope of practice for UAP. Administration of medication, obtaining cultures, and evaluation are higher level skills that require the education and scope of practice of licensed nursing personnel.
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage c. Punch biopsy b. Cryosurgery d. Surgical excision
ANS: D The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and cryosurgery are not used if malignancy is suspected.
The nurse is preparing to assist the HCP in obtaining a full-thickness skin biopsy. Which information from the nurse is most appropriate? 1. Explain that the surface of the biopsy area will be shaved off. 2. Inform the patient that a thick area of skin will be punched out. 3. Tell the patient that the most pain will be in numbing the area. 4. Instruct the patient to expect considerable bleeding to occur.
ANS: 3 If the HCP plans a full-thickness biopsy, the technique will not involve shaving off the surface of the lesion.
The nurse works in an extended-care facility and is assisting in the development of a policy and procedure addressing foot care of the residents. Which intervention does the nurse identify as needing to be reconsidered in regard to routine foot care? 1. Soak the residents' feet briefly in warm water and wash with gentle soap. 2. Use gauze or pads to reduce pressure where toes lie across each other. 3. Use a pumice stone to remove dry skin from heels or callused areas. 4. Apply an alcohol-free
ANS: 3 Soaking the feet of residents in warm water for a brief period of time before washing the feet with a gentle soap is appropriate care
The nurse is assisting with a patient who has a suspected diagnosis of tinea capitis (ringworm). For which diagnostic test does the nurse prepare the patient? 1. Patch test 2. Scratch test 3. Skin biopsy 4. Wood's light examination
ANS: 4 A patch test is performed when allergic contact dermatitis is suspected. A scratch test is performed when allergic contact dermatitis is suspected.
The nurse is assisting with a skin examination for a patient. The patient asks, "I love the sun, why is everyone so concerned about sun exposure?" Which answer by the nurse is best? 1. "Sun exposure will cause the skin to age and wrinkle." 2. "The sun gives off ultraviolet (UV) rays that destroy vitamin D." 3. "Melanin pigment is a barrier against UV exposure." 4. "UV rays are mutagenic and can cause skin cancers."
ANS: 4 Sun exposure can contribute to skin aging and the development of wrinkles; however, this is not the best answer regarding sun exposure
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"
ANS: A The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics.
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.
ANS: A The patient should stay out of the sun. If that is not possible, teach the patient to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate.
A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."
ANS: B The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place.
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. c. Water resistant sunscreens will provide good protection when swimming. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
ANS: B The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and it will take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because of the risk for infection caus
ANS: B Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's 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.
ANS: B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion.