NURS 3107 - Exam 4 - EAQs: Integumentary Assessment, Ch. 24 NCLEX Practice, DavisEdge Quiz: Nursing Care of Patients with Skin Disorders

A nurse is dressing the wound of a patient whose fingers were injured in an accident. One of the fingernails is missing. The patient asks the nurse about when the fingernail will grow back. What is the most appropriate answer? Within 3 months Within 6 months Within 12 months Within 15 months

Within 6 months In healthy individuals, a lost fingernail usually regenerates in three to six months. Therefore, the most appropriate answer given by the nurse would be within six months.

The nurse is caring for a group of clients. Which client should the nurse see first?

A client with burns who has developed stridor

Which of the following is the most common type of cancer in the United States?

Skin

The nurse is teaching a client about preventing skin cancer. Which statement made by the client indicates an understanding of the teaching?

"I need to cancel my tanning membership."

The nurse is caring for a client undergoing a scratch test for allergies. Which of the following statements made by the client requires correction by the nurse?

"I should put baby oil on my skin so the patch sticks better."

A nurse educator explains to a group of nursing students why skin becomes darker in color when exposed to sunlight. Which statement by a student indicates the teaching has been understood? "The rays from the sun stimulate the production of melanin, giving a tan to the skin." "The rays from the sun inhibit the production of melanin, causing the skin to darken." "The rays from the sun burn the outer layer of the skin, making the skin dark and painful." "The rays from the sun cause increased blood flow to the skin, giving a dark red color to the skin."

"The rays from the sun stimulate the production of melanin, giving a tan to the skin." Sunlight stimulates an organelle known as melanosome, which is present in the melanocytes (the cells responsible for production of melanin). Stimulation of melanosome causes increased production of melanin, which gives the dark color (tan) to the skin. Extreme sun exposure can burn the skin, and the skin may become dark and painful due to sunburns. Heat in summer causes vasodilatation, which causes temporary reddening of the skin.

The nurse is caring for a client with scabies. Which of the following interventions should the nurse implement?

Apply permethrin as ordered.

The nurse is reviewing orders for a client with psoriasis. Which medication should the nurse question?

Nadolol [Beta blockers can cause a flare-up of psoriasis and should be avoided]

The nurse is caring for a client with cellulitis of the right lower leg. Which of the following clinical manifestations can the nurse expect to find?

Redness

The nurse is caring for a client with burns. Which of the following interventions should the nurse implement during the emergent stage? Select all that apply.

1. Remove clothing 2.Cool the wound with tepid water

A patient had an infection underneath the toenail, and the entire nail was removed. The patient asks the nurse how long it will take the toenail to grow back to its normal size. What should be the nurse's answer? 1-2 months 3-6 months 6-12 months 12-24 months

12-24 months Sometimes toenails may be removed due to ingrowth and infection. Toenails grow at a rate of 30% to 50% slower than fingernails. The nail growth may vary depending upon the person's age and health. A toenail would usually fully regenerate in 12 months or longer. Fingernails grow back in 3-6 months.

A patient is having a diagnostic test performed to check a skin rash for a possible fungal infection. The nurse will prepare for which test? A patch test A shave biopsy A potassium hydroxide (KOH) microscopic test The Tzanck test (Wright's and Giemsa's stain)

A potassium hydroxide (KOH) microscopic test A KOH test is done to examine hair, scales, or nails for superficial fungal infection. A patch test is done to check for allergic reactions. A shave biopsy is done to provide a thin specimen for diagnostic purposes. The Tzanck test is done to assess for the presence of the herpes virus.

The patient is in the hospital for a surgical procedure and has dry skin and pruritis on her legs that causes her to scratch at the skin uncontrollably. What measures can the nurse use to help stop the itch/scratch cycle 0?(select all that apply)? A. Moisturize the skin on the legs. B. Provide a warm blanket and room. C. Administer antihistamines at bedtime. D. Use careful hand washing after rubbing her legs. E. Cleanse the legs with a saline solution twice daily.

A, C A. Moisturize the skin on the legs. C. Administer antihistamines at bedtime. Moisturizing the skin to decrease the dryness and the itch sensation and bedtime antihistamines to decrease a potential allergic reaction and provide some sedation will help the patient sleep since pruritis is often worse at night and the patient needs sleep for healing. Using nonallergic sheets may also help. Anything causing vasodilation, such as warmth or rubbing, should be avoided. Saline solution would only further dry the skin so would not be used on the patient's legs.

Which patient would be more likely to have the highest risk of developing malignant melanoma? A. A fair-skinned woman who uses a tanning booth regularly B. An African American patient with a family history of cancer C. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia D. A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment

A. A fair-skinned woman who uses a tanning booth regularly Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy, and a family history of other cancers are less likely to be linked to malignant melanoma.

Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot? A. Applying warm, moist heat B. Wrapping the foot snugly in blankets C. Limiting ambulation to three times daily D. Keeping the foot at or below heart level

A. Applying warm, moist heat The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Immobilization and elevation is also used. Snug blankets would not be helpful and could decrease circulation to this sensitive tissue.

The patient has been diagnosed with tinea unguium (Onychomycosis) under her nails. She does not like the oral antifungal medication. What is the best alternate treatment the nurse should describe for her? A. Nail avulsion B. Antifungal cream C. Thinning of fingernails D. Soaking nails in salt water

A. Nail avulsion Nail avulsion is the best alternate treatment to the oral antifungal medication. Antifungal cream is minimally effective. Thinning fingernails is not needed if the tinea unguium is under her toenails. Soaking the nails will not be helpful.

The patient with a stage IV pressure ulcer on the coccyx will need a skin graft to close the wound. What postoperative care should the nurse expect to use to facilitate healing? A. No straining of the grafted site B. The wound will be exposed to air. C. Soft tissue expansion will be done daily. D. The pressure dressing will not be removed.

A. No straining of the grafted site Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound's skin graft.

The nurse would assess a patient admitted with cellulitis for what localized manifestation? A. Pain B. Fever C. Chills D. Malaise

A. Pain Pain, redness, heat, and swelling are all localized manifestation of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot? A. Redness and swelling B. Pallor and poor turgor C. Cyanosis and coolness D. Edema and brown skin discoloration

A. Redness and swelling Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, heat, and tenderness in the affected area. These changes accompany the processes of inflammation and infection.

The nurse should teach a patient who is taking which drug to avoid prolonged sun exposure? A. Tetracycline B. Ipratropium C. Morphine sulfate D. Oral contraceptives

A. Tetracycline Several antibiotics, including tetracycline, may cause photosensitivity. This is not the case with ipratropium, morphine, or oral contraceptives.

The nurse is caring for a client with impetigo. Which of the following clinical manifestations can the nurse expect to find?

Honey-colored crusting

The nurse is assessing a patient who has dark skin for cyanosis. What assessment findings would indicate cyanosis in individuals with dark skin? Reddish skin tone Deeper brown or purple skin tone Grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, palms, and soles Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds

Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds In dark-skinned individuals, cyanosis may be noted as an ashen or gray color most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds. Reddish, deep brown, purple, and grayish blue skin tones are not signs of cyanosis in dark-skinned individuals. The grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, and so forth indicates cyanosis in light-skinned individuals.

The nurse should recognize which patient as likely to have the poorest prognosis? A. A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma B. A 59-year-old man who is being treated for stage IV malignant melanoma C. A 70-year-old woman who has been diagnosed with late squamous cell carcinoma D. A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma

B. A 59-year-old man who is being treated for stage IV malignant melanoma Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late squamous cell carcinoma (SCC) has worse outcomes than superficial SCC, these are both exceeded in mortality by late-stage malignant melanoma.

Which assessment finding of a 70-year-old male patient's skin should the nurse prioritize? A. The patient's complaint of dry skin that is frequently itchy B. The presence of an irregularly shaped mole that the patient states is new C. The presence of veins on the back of the patient's leg that are blue and tortuous D. The presence of a rash on the patient's hand and forearm to which the patient applies a corticosteroid ointment

B. The presence of an irregularly shaped mole that the patient states is new Although all of the noted assessment findings are significant, the presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate follow-up.

The patient has had rashes and alopecia. What vitamin in which foods should be encouraged as a nutritional aid to these problems? A. Vitamin A in sweet potatoes, carrots, dark leafy greens B. Vitamin B7 (biotin) in liver, cauliflower, salmon, carrots C. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi D. Vitamin D in canned salmon, sardines, fortified dairy, and eggs

B. Vitamin B7 (biotin) in liver, cauliflower, salmon, carrots A deficiency of Vitamin B7 (biotin) may result in rashes and alopecia. Eating foods with biotin will help decrease these problems. Vitamins A and C are needed for wound healing. Vitamin D is needed for bone and body health.

Which laboratory result is the best indicator that a patient with cellulitis is recovering from this infection? A. WBC of 2900/μL B. WBC of 8200/μL C. WBC of 12,700/μL D. WBC of 16,300/μL

B. WBC of 8200/μL The normal white blood cell count is generally 4000 to 11,000/μL. For this reason, the patient's level would be returning to normal if it was 8200/μL, indicating recovery from cellulitis. The 2900/µL is too low and indicates another problem is occurring. The 12,700/µL and 16,300/µL are evidence of continuing infection.

A nurse is obtaining a sample for an indirect immunofluorescence test for a patient suspected of having systemic lupus erythematosus (SLE). Which type of sample does the nurse expect to collect? Blood Throat swab Punch biopsy specimen of the skin Shave biopsy specimen of the skin

Blood Indirect immunofluorescence is an investigation required to identify the abnormal antibodies causing diseases such as SLE. A blood sample is required for indirect immunofluorescence testing. A throat swab specimen is not required for this test. Throat swabs are generally required for identifying the causative organisms of throat infections. Punch biopsy and shave biopsy skin specimens are not useful for indirect immunofluorescence but can be used as a test sample for direct immunofluorescence.

The nurse is caring for a client with cellulitis. Which of the following warrants a telephone call to the health-care provider?

Blood pressure 80/42 [Hypotension could indicate a systemic infection]

A nurse asks a nursing student to determine the skin color of a patient whose skin is tanned in the exposed areas. Where is the best place on a patient's body to accurately determine skin color? Face Palms Buttocks Nail beds

Buttocks In order to find out the actual skin color of the patient, the nursing student should observe the skin color in photo-protected areas such as the buttocks. The face is not a reliable area to assess skin color because it is exposed to the sun. The nail beds and palms have less melanin content and are therefore not reliable areas to assess skin color.

The nurse is providing preoperative teaching for the patient having a face-lift (rhytidectomy) surgery. Which patient response indicates the patient understands the teaching? A. "I am afraid of the pain afterwards, while it is healing." B. "I can't wait to have my forehead and lip wrinkles eliminated." C. "I have some time off work so I will not look so bad when I go back." D. "Now I can be excited to go to my 50th high school reunion this week.

C. "I have some time off work so I will not look so bad when I go back." A rhytidectomy or face-lift surgery will not have immediate results and will take time to heal, so taking time off from work will allow more healing to be accomplished before returning to work. There is not much pain with most cosmetic surgeries. A rhytidectomy will not eliminate forehead lines and vertical lip wrinkles.

The patient with diabetes mellitus has peripheral vascular disease. Knowing this, for which dermatologic manifestations should the nurse expect to assess? A. Redness of exposed areas of the skin on the hand, foot, face, or neck and infected dermatitis B. Leathery, brownish skin on lower leg, pruritis, concave lesions with edema, scar tissue with healing C. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing D. Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

C. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing The patient with diabetes mellitus and peripheral vascular disease is likely to have loss of peripheral hair, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing. The patient with a nicotinic acid (niacin) deficiency manifests redness of exposed areas of the skin on the hand or foot, face, or neck and infected dermatitis. The patient with venous ulcers will have leathery, brownish skin on the lower leg, pruritus, concave lesions with edema, and scar tissue with healing. The patient with glucocorticoid excess (Cushing syndrome) may have atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck, clavicles, abdomen, and face.

A 56-year-old white patient presents with a flat, dry, scaly area on her eyebrows that is treated with a chemical peel. What should the nurse include in the discharge teaching? A. Metastasis of this type of cancer is rare. B. The patient has an increased risk for melanoma. C. Recurrence of the premalignant lesion is possible. D. Untreated lesions may metastasize to regional lymph nodes.

C. Recurrence of the premalignant lesion is possible. The flat or elevated dry scaly area is actinic keratosis from sun damage and is a premalignant skin lesion common in older whites with possible recurrence even with adequate treatment. Metastasis of basal cell carcinoma is rare; it is a small slowly enlarging papule. There is an increased risk for melanoma with atypical or dysplastic nevi. With squamous cell carcinoma, untreated lesions may metastasize to regional lymph nodes and distant organs, but it has a high cure rate with early detection and treatment.

A 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? Warm, flushed skin, alopecia, and thin nails General hyperpigmentation and loss of body hair Pale skin, pale mucous membranes, hair loss, and nail dystrophy Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails

Cold, dry, pale skin; dry, coarse hair; and 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.

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 most suspect to be the cause of the odor? Ecchymosis Colonization by yeast or bacteria Age-related integumentary changes Atrophy of the skin under the abdominal folds

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.

To determine the presence of petechiae in a patient with dark skin, the nurse should assess what part of the body? Nail Face Buttocks Conjunctiva

Conjunctiva Petechiae are small pinpoint lesions. The nurse should check for these lesions in the conjunctiva of the eye or buccal mucosa in dark-skinned people. Unlike fair-skinned people, these lesions are difficult to see on the nail, face, or buttocks of dark-skinned people.

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

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 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? Lips Legs Wrists Sclera

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. It is not as likely on the legs, wrists, or sclera.

A 26-year-old patient is looking down as she tells the nurse that she is afraid to use the treatment recommended for her psoriasis because her mother had a lot of problems with all the creams she used to try to treat her psoriasis. How should the nurse respond to the patient? A. "You will only know if you try it and see." B. "You may need to get counseling to help you cope." C. "No treatment is medically necessary, but it can be removed." D. "Topical, light therapy, and systemic medications are now available."

D. "Topical, light therapy, and systemic medications are now available." Treatment of psoriasis usually involves a combination of strategies including topical treatments, phototherapy, and/or systemic medications including biologic drugs. Telling her that she will only know if she tries or that she may need counseling is denying the patient's concern. Psoriasis is treated to manage the disease as the patient may have a weakened immune system and be at risk for cardiovascular disease.

To the nurse, a patient describes small, firm, reddened raised lesions with flat, rough patches that are causing intense pruritus. What should be the nurse's next assessment? A. History of seasonal allergies B. Initiation of new medication C. Previous pruritic skin lesions D. Activities in past 2 to 7 days

D. Activities in past 2 to 7 days The patient's lesions are papules and plaques characteristic of contact dermatitis. The nurse should ask the patient about activities over the past 2 to 7 days to identify potential allergens because contact dermatitis has a delayed onset. Even if an offending agent is not identified, the nurse can provide patient teaching about managing the pruritus and preventing infection by decreasing scratching. Seasonal allergies and new medications are more likely to cause urticaria than papules and plaque. The nurse should also ask about pruritic rashes in the past to determine potential illnesses that can cause dermatologic manifestations.

What practice should the nurse teach a patient to follow when the patient is applying topical medication? A. Avoid applying medications directly on to dressings. B. Use a tongue blade whenever the patient's skin integrity allows. C. Avoid covering skin regions that have topical medication in place. D. Apply a layer of medication that is just thick enough to ensure coverage.

D. Apply a layer of medication that is just thick enough to ensure coverage. Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat.

The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching? A. Use cool compresses if an infection occurs. B. Oral antibiotics will be needed for any skin changes. C. Antiviral agents will be needed to prevent outbreaks. D. Inspect skin for changes when bathing with mild soap.

D. Inspect skin for changes when bathing with mild soap. Individuals living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin's surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the antiinflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks.

A patient reports excessive itchiness all over the body that has caused an inability to sleep for three days. What nursing assessment finding indicates a lack of proper sleep? Dry, scaly skin Supple, moist skin Reddening of the skin Dark circles under the eyes

Dark circles under the eyes Excessive tiredness or sleeplessness causes dark circles under the eyes because of dullness and dehydration. Dry and scaly skin causes itching but is not directly associated with sleeplessness. Reddening of the skin and the presence of supple, moist skin are not indicative of disturbed sleep. Reddening of skin is a manifestation of dilated blood vessels. Suppleness and good hydration are indicators of healthy skin.

A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply. Decrease in the production of melanin Increase in the production of melanin Increase in the number of melanocytes Decrease in the number of melanocytes Decreased exposure to sun in old age

Decrease in the production of melanin Decrease in the number of melanocytes With aging, the number of melanocytes decreases, causing a decrease in melanin production. An increase in the number of melanocytes causes an increase in the production of melanin, which is characterized by tanning of skin and darkening of hair. Exposure to sun is not related to the greying of hair.

A nurse is discussing the health changes associated with aging with a group of older adults in a community clinic. One of the members of the group asks about dry skin and aging. The nurse explains that, in the elderly population, dry skin comes with aging due to what? Select all that apply. Decreased production of sebum. Decreased immunocompetence. Decreased subcutaneous fat tissue. Decreased blood supply to the skin. Decreased water content in the body.

Decreased production of sebum. Decreased water content in the body. Dry skin comes with aging because of decreased activity of the sweat and sebaceous glands. Sebum is a lipid-rich substance that prevents the skin and hair from becoming dry. Decreased water content in the skin is another important cause for drying of skin in old age. A decrease in immune functioning with aging increases the patient's susceptibility to infections. A decrease in subcutaneous fat content as a person ages causes wrinkling of skin and inelasticity of fibrous tissue of breasts and abdomen. A decreased blood supply causes a pale appearance and low temperature of the extremities.

During an initial assessment of an obese female patient, what specific question should the nurse ask to determine the metabolic pattern related to her skin? Is your sleep being disturbed by any skin condition? Is there any specific food that also causes a skin allergy? Do you have any chafing or a rash in areas where skin overlaps? Are there any skin changes during exercise or other activities?

Do you have any chafing or a rash in areas where skin overlaps? The nurse should ask the obese female patient about areas of chafing or a rash in intertriginous areas. These are the areas where skin surfaces overlap and rub on each other, for example below the breasts, axillae, and groin. These areas are more prone to skin breakdown and rashes. Other questions related to elimination, exercise activity, and sleep-rest pattern are not directly related to the metabolic pattern of skin.

When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. Fissure Dry skin Wrinkling Excoriation Decreased turgor

Dry skin Wrinkling Decreased turgor

The nurse is teaching a 75-year-old client about immunizations. Which of the following should the nurse include in the teaching?

Encourage the client to receive the shingles vaccination.

A nurse is performing a skin assessment on a female patient. The patient has excessive hair on the chest and the face. The nurse expects that what test will be performed? Skin biopsy Estrogen test Thyroid function test Blood test to determine clotting time

Estrogen test

A nurse is assessing a patient who has yellow skin and nails. Which chemical or pigment abnormality does the nurse expect the patient to have? Excess melanin Excess carotenes Excess oxyhemoglobin Excess deoxyhemoglobin

Excess carotenes Excess carotene in the body gives a yellow color to the skin. Excess melanin in the body gives a brown color to the skin. Excess oxyhemoglobin gives a red color to the skin. Excess deoxyhemoglobin gives a blue color to the skin.

A nurse is performing skin assessment on a patient. The patient is obese and a security guard by profession. The patient's skin on the sole of the feet is extremely hard and thick. What is the most likely cause for this finding? Injury to the sole Diminished blood supply to the feet Excessive pressure due to weight bearing Infection of the feet causing lesions in the soles

Excessive pressure due to weight bearing Thickened calluses over the heels are normal and occur due to pressure of weight bearing. The patient is obese and a watchman by profession; therefore, the patient may spend more time standing. Thus the most likely cause of thickened skin of the sole is excessive pressure due to weight bearing. Injury, diminished blood supply, and foot infections are less likely causes of thickening and hardening of the skin of the sole.

Which of the following burn locations would lead the nurse to assess for inhalation injury?

Face

Which data would a nurse consider least important during an assessment of skin integrity? Family history of pressure ulcers Presence of existing pressure ulcers Overall risk as indicated by a low Braden score Areas at risk for the development of pressure ulcers

Family history of pressure ulcers Family history is not an important factor in the development of pressure ulcers and general skin integrity. A patient deemed to be at risk on the basis of a validated tool such as the Braden scale and existing areas of skin breakdown requires immediate assessment and intervention.

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? Scar Fissure Atrophy Excoriation

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 an 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 the epidermis is missing, which exposes dermis (e.g., abrasion or scratch).

The nurse is caring for a client with chemical burns. Which of the following interventions should the nurse implement?

For ALL chemical burns, initiate immediate copious tepid water lavage for 20 minutes. [Neutralizing the chemical takes too much time, do not do this]

A teenaged patient reports having blackheads all over the face for the past year. The nurse recognizes that, for this patient, the blackheads are due to excessive sebum production most likely caused by what? Infections Hormonal alterations Environmental changes Sebaceous gland carcinoma

Hormonal alterations Hormonal changes occurring during puberty stimulate the sebaceous glands to produce more sebum. This plays a major role in causing acne and the development of comedones (blackheads). Infections, environmental alterations, and sebaceous gland carcinoma may also cause comedones but are less likely in this case.

When assessing a dark-skinned patient, the nurse finds that there are dark longitudinal bands in the patient's nail beds. What is the most likely interpretation of this finding? The patient may have psoriasis. It is a normal finding in this patient. Anemia may be present in this patient. The patient may have a thyroid disorder.

It is a normal finding in this patient. Dark longitudinal bands (melanonychia striata) in the nail bed are a common occurrence in people with darker skin pigmentation. In conditions related to thyroid disorders, anemia, and psoriasis, there are changes in the thickness and smoothness of the nail bed.

The patient has diffuse distribution of moles on the body. A biopsy of one on the patient's back will be done to assess for malignancy. The nurse knows that what is the rationale for doing a punch biopsy? It is used for a superficial lesion. It provides a full-thickness of skin. It is used for good cosmetic results. It is used because the lesion is too large to remove.

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.

Which disease condition can be found more in fair-skinned patients than in patients with more pigmentation in their skin? Keloids Melanoma Nevus of ota Traction alopecia

Melanoma Fair-skinned people are more prone to developing melanoma as compared to people with more pigment in their skin. People with darker skin have an increased amount of melanin pigment produced by the melanocytes. This increased melanin forms a natural sun shield for darker skin tones and results in a decreased incidence of skin cancer in these individuals. However, individuals with dark skin may have increased incidence of keloids, nevus of ota, and traction alopecia.

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. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system? Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

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.

When jaundice is suspected in a patient, which areas should the nurse check for skin color? Select all that apply. Tongue Nail beds Earlobes Conjunctiva Buccal mucosa

Nail beds Conjunctiva Buccal mucosa Changes in skin color may vary from one person to another. The skin color depends on the amount of melanin, carotene, oxyhemoglobin, and reduced hemoglobin present at a particular time. The most reliable areas to assess for erythema, cyanosis, pallor, and jaundice are the sclerae, conjunctivae, nail beds, lips, and the buccal mucosa, as these areas are the least pigmented. The tongue and earlobes are not reliable areas to assess for skin color.

A nurse is teaching a group of nursing students about the perception of cold in obese people. Which statement should be included in the education? Obese people have fewer cold receptors. Obese people have better fat insulation. Obese people have better cold tolerance. Obese people have an abnormal hypothalamic functioning.

Obese people have better fat insulation. Obese people have large amounts of subcutaneous adipose tissue. This tissue provides good thermal insulation. Obesity alone does not cause individuals to have fewer cold receptors, better cold tolerance, or abnormal hypothalamic functioning.

When assessing the patient's integumentary system, which dermatologic manifestations may indicate systemic problems? Select all that apply. Pallor Jaundice Skin tags Cyanosis Cherry angiomas

Pallor Jaundice Cyanosis Pallor, jaundice, and cyanosis are dermatologic manifestations that may indicate systemic problems. Jaundice is often an indication of a liver problem. Pallor indicates anemia, and cyanosis may be due to a respiratory disorder. Skin tags and cherry angiomas are benign neoplasms related to aging.

To assess the skin turgor, the most appropriate technique for the nurse to use is which of these? Palpation Inspection Percussion Auscultation

Palpation Turgor refers to the elasticity of the skin. Assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released. Inspection, percussion, and auscultation are not useful for assessing skin turgor.

To obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use? Inspection of skin color Examination for vascularity Palpation of skin with the hand Percussion of the skin on the back

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.

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. Patient's sclera Patient's nail beds Soles of the patient's feet Palms of the patient's hands Conjunctiva of the patient's eyes

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

A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. Which term best describes these findings? Purpura Petechiae Hematoma Ecchymosis

Petechiae Petechiae are small pink-to-purplish macular lesions 1 to 3 mm in diameter, usually caused by minor hemorrhage of capillary blood vessels. Purpura are red or purple discolorations of the skin that do not blanch when pressure is applied. Purpura are associated with bleeding under the skin and are seen in various bleeding disorders. A hematoma is a localized collection of blood outside blood vessels that is generally the result of hemorrhage. Ecchymosis is a collection of blood under the skin, larger than a petechiae, with diffuse borders.

The nurse is caring for a client with dermatitis. Which interventions will the nurse implement?

Provide skin care at bedtime. [cold compresses should be used, ask pt to pat the skin dry to avoid trauma and eat a diet high in protein]

A nurse is assessing a male client who reports small papules and pustules in the beard area. The papules started appearing after he shaved his beard the previous day. Based on this information, what is the most likely patient diagnosis? Acne Moles Comedo Pseudofolliculitis

Pseudofolliculitis Pseudofolliculitis is an inflammatory reaction that occurs in the beard area after shaving too closely. This inflammation is a response to the in-growth of hair after shaving and is manifested as pustules or papules. Acne is also characterized by papules and pustules but is unlikely to occur in the beard area after shaving. Acne is usually due to an infection or hormonal changes. Moles are small, dark lesions caused by benign overgrowth of melanocytes. Comedos (blackheads and whiteheads) are enlarged hair follicles that are plugged with sebum, bacteria, and skin cells. They may occur due to heredity, drugs, or hormonal changes.

A 14-year-old girl and her mother come to see the nurse practitioner for treatment of the daughter's acne. For what should the nurse assess the patient to show the existence of acne? Ulcers Wheals Vesicles Pustules

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.

Which process should a nurse follow when obtaining a wound culture from a surgical site? Rolling a sterile swab from the center of the wound outward Using a sterile swab, starting on the outer edge of the wound Thoroughly irrigating the wound before collecting the culture Using a sterile swab to wipe the crusted area around the outside of the wound

Rolling a sterile swab from the center of the wound outward Rolling the swab from the center outward is the correct procedure for culturing a wound. Starting on the outer edge of the wound, irrigating the wound before collecting the culture specimen, and using a sterile swab to wipe the crusted area may contaminate the wound, produce inaccurate results, or both.

The nurse is performing a skin assessment. What is the best location to assess for jaundice?

Sclera

Which of the following are age-related changes of the integumentary system?

Skin becomes thin [Elasticity and activity of sweat glands decrease, skin becomes more fragile]

Which stage of pressure injury is shown here? (Picture: Shallow wound)

Stage II

The nurse is assessing a client with burns. For which of the following findings should the nurse notify the health-care provider?

Stridor [Can be indicative of a reduced airway]

A nurse is giving a lecture on nutrition to a group of nursing interns. The nurse says that sunlight is the best source of vitamin D. Based on their previous knowledge, what would be the most appropriate interpretation of this statement by the interns? Sunlight stimulates the production of vitamin D in the body. Sunlight contains vitamin D, which is easily absorbed by the skin. Exposure to sunlight increases craving for foods rich in vitamin D. Sunlight causes proliferation of the cells containing vitamin D precursors.

Sunlight stimulates the production of vitamin D in the body. The ultraviolet (UV) rays present in sunlight act on the vitamin D precursors present in epidermal cells and form Vitamin D. Sunlight does not contain vitamin D. Exposure to sunlight does not increase craving for foods rich in Vitamin D. The UV rays do not help in proliferation of Vitamin D precursors but simply convert them to vitamin D.

On inspection of a patient's skin, the nurse notes dilated, superficial, cutaneous small blood vessels on the patient's face. What is this assessment finding called? Vitiligo Intertrigo Petechiae Telangiectasia

Telangiectasia Telangiectasia are visibly dilated, superficial, cutaneous small blood vessels, commonly found on face and thighs. Vitiligo is a chalky, white patch that occurs because of a complete absence of melanin (pigment). Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membrane. Intertrigo is a dermatitis of overlying surfaces of the skin.

During an assessment interview of a female patient, the nurse finds that she is taking isotretinoin to treat acne. On further assessment, the patient expresses that she plans to conceive. Which is the most important nursing action? Teach the patient to take the drug with food to minimize the side effects. Inform the patient she can continue this medication because the acne has reduced. Tell the patient to stop this medication because it would have adverse effects on the fetus. Inform the patient that an overdose of Accutane can have serious consequences during pregnancy and tell her to reduce the dose.

Tell the patient to stop this medication because it would have adverse effects on the fetus. The drug isotretinoin is used for treating acne. The drug can cause abnormal fetal development and should not be used by women who are pregnant or are planning to become pregnant. Whereas a nurse would normally discuss the drug's side effects and effectiveness, these issues are not relevant if the patient is instructed to discontinue the medication while trying to conceive.

A nurse is caring for a patient who has taken a potassium hydroxide (KOH) skin test. The results of the test are positive. What would be the interpretation of this test? The patient has a skin allergy. The patient has a malignant skin condition. The patient has a fungal infection of the skin. The patient has systemic lupus erythematosus (SLE).

The patient has a fungal infection of the skin. The KOH test indicates the presence of a fungal infection. The KOH test cannot be used to establish the presence of skin allergy, malignant skin condition, or SLE. A skin allergy is best tested with the patch test. The diagnosis of a malignant skin condition is done by a skin biopsy. Direct immunofluorescence is a special diagnostic technique used on a biopsy specimen to confirm SLE.

A nurse is assessing a patient with psoriasis. The nurse explains the pathology of psoriasis, stating that it occurs due to abnormal changes in the cell cycle of the skin layers. Which change in the cell cycle is the nurse referring to? The outer dead layer of skin cells is not shed. The inner layer of skin stops producing new skin cells. The rate of removal of outer dead skin is much more than the rate of production of new skin cells. The rate of new skin cell production is much more than the rate of removal of outer dead skin cells.

The rate of new skin cell production is much more than the rate of removal of outer dead skin cells. In psoriasis, new skin cells are formed faster than old cells are shed. This causes the skin in psoriasis patients to become scaly and thickened. In psoriasis, the outer layer of the dead skin is shed at a normal rate. The inner layer of the skin does not stop producing new skin cells but produces new skin cells at a much faster rate. If the rate of removal of outer dead skin is much more than the rate of production of new skin cells, the skin becomes too thin.

A nurse educator is teaching a group of nursing students about skin assessments. The nurse asks the students the reason for assessment of cyanosis, pallor, and jaundice in the nail beds, sclera, and lips. What is the most appropriate response by the students? These areas have the least pigmentation. These areas have the highest blood flow. These areas are rich in sensory receptors. These areas are the most accessible to a nurse.

These areas have the least pigmentation. Cyanosis, pallor, and jaundice all indicate the presence of systemic diseases. The most reliable areas for assessing these signs are nail beds, lips, sclerae, and conjunctivae, because these areas contain the least amount of pigmentation. As a result, changes in color can be easily identified. The nail beds, sclera, and lips are easily accessible; however, that is not a reason for the choice of the area during color assessment. These areas may not have high blood flow or a high amount of sensory receptors.

During the 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? Tiny, purple spots on the skin Large ecchymotic areas on the skin Hyperkeratotic papules and plaques Small, raised red areas on the soles of the feet

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 scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture? To identify an allergen To identify a fungal infection To identify a viral infection To identify a bacterial infection

To identify a fungal infection Culture of the skin lesion specimen is used to identify the fungal, bacterial, or viral infection. Scraping or swab of the skin is performed to obtain the specimen for identification of fungal infection. For bacteria, the sample for culture is obtained from intact pustules, bullae, or abscesses. For a virus, the vesicle or bulla and exudates are taken from the base of the lesion. Culture cannot be used to determine the agent causing skin allergies. The patch test is used to determine the allergen causing the skin lesions.

While explaining the structure of the skin to a patient, the nurse says that the outermost layer of the skin consists mainly of dead cells. The patient asks the nurse, "Why do our bodies need these dead cells?" What is the most appropriate answer for the nurse to give? To protect the viable cells underneath To preserve water for the viable cells underneath To provide nutrition to the viable cells underneath To provide antiseptic properties that prevent infection in the body

To protect the viable cells underneath The outermost layer of the skin is known as the epidermis. This layer is composed primarily of dead cells, which act as a protective layer for the deeper viable skin tissue. Because this layer is composed mainly of dead cells, these are not useful to provide nutrition to the deeper skin tissues (dermis). The epidermis is a dry layer of cells; it does not preserve water. The epidermal layer has no antiseptic properties.

Which of the following is shown here? (Picture: A small, blister like raised area of the skin that contains serous fluid. Up to 1cm in diameter)

Vesicle

The nurse assessed the patient's skin lesions as circumscribed, with a superficial collection of serous fluid, and less than 0.5 cm in diameter. What term describes these lesions? Wheals Papules Pustules Vesicles

Vesicles Vesicles are circumscribed, with superficial collection of serous fluid, less than 0.5 cm in diameter. Examples include varicella (chickenpox), herpes zoster (shingles), and second-degree burn. Wheals are firm, edematous areas such as insect bites. Papules are solid lesions (warts). Pustules are fluid-filled lesions (acne or impetigo).

A nurse is assessing a patient with chalky, white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis? Keloid Vitiligo Intertrigo Hypopigmentation

Vitiligo Vitiligo is a skin condition characterized by complete loss of melanin in the affected area, which results in chalky, white patches. This condition is usually inherited. Keloid is an overgrowth of scar tissue at the site of skin injury. Intertrigo is characterized by presence of rashes in intertriginous areas, such as the axillae and the area under the breast. It is usually due to inflammation of the overlying surface of skin. Hypopigmentation also occurs due to loss of pigmentation but is not an inherited disorder. Hypopigmentation is usually due to chemical agents, nutritional factors, burns, inflammation, or infection.

The nurse is providing teaching for a client with lice. Which of the following should the nurse include in teaching?

Wash clothes, linens, and towels in hot water and detergent.