Prep U's - Chapter 55 - Assessment of Integumentary Function
Sudoriferous glands secrete which type of substance? A. Sweat B. Hormones C. Oil D. Cerumen
Answer: A Rationale: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? A. Make sure that the room is darkened. B. Obtain samples of the lesion by scraping. C. Apply a special dye to the area. D. Protect the patient from the light.
Answer: A Rationale: When performing a Wood's light examination, the nurse would need to ensure that the room is darkened to allow visualization of the fluorescent light so that he or she can differentiate epidermal from dermal lesions. Dye is used for immunofluorescence. There is no need to protect the patient from the light. Skin scrapings involve obtaining samples of the lesion.
A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: A. Palpable, solid tumors >3 cm. B. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. C. Flat, mole-like lesions. D. Flat macules with irregular borders.
Answer: B Rationale: Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.
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? A. Melanoma B. Psoriasis C. Vitiligo D. Petechia
Answer: B Rationale: Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.
A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum? A. contributing to acidity of perspiration to decrease microbial growth. B. cooling overwarm skin. C. prevents drying and cracking of the skin and hair. D. trapping debris in the external ear.
Answer: C Rationale: Sebum, which is an oily lubricant, prevents drying and cracking of the skin and hair.
A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? A. Psoriasis B. Local trauma C. Anemia D. Hypoxia
Answer: D Rationale: Clubbing is an indication of hypoxia, which may be the result of the patient's chronic respiratory illness. Severe iron-deficiency anemia may be indicated by spoon-shaped nails. Beau's lines, transverse depressions of the nail, suggest local trauma. Pitted nails indicate psoriasis.
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? A. Protein deficiency B. Sebum deficiency C. Dehydration D. Fluid retention
Answer: D Rationale: Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.
Which diagnostic test is used to examine cells from herpes zoster? A. Tzanck smear B. Skin biopsy C. Skin scrapings D. Patch testing
Answer: A Rationale: A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scraping is used to diagnose spores and hyphae. A patch test is used to identify substances to which the client has developed an allergy.
An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding? A. It is a cherry angioma that is a normal age-related skin alteration. B. It is an ecchymosis that is associated with trauma and bleeding. C. It is a spider angioma that is associated with liver disease. D. It is a telangiectasia that is associated with varicose veins.
Answer: A Rationale: A cherry angioma is a papular and round area that is red, found on extremities, and may blanch with pressure. This lesion is considered a normal age-related skin change. A spider angioma is red with a central body and radiating branches that is associated with liver disease. A telangiectasia has a shape like a spider that is caused by the dilation of venous vessels and varicose veins. Ecchymoses are round or irregular macular lesions that vary in color and are associated with trauma or bleeding.
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? A. Scale B. Ulcer C. Scar D. Crust
Answer: A Rationale: A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.
Which of the following describes a total absence of pigment melanin? A. Albinism B. Vitiligo C. Anemia D. Cyanosis
Answer: A Rationale: Albinism is the total absence of the pigment melanin. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of the skin. Anemia is a decreased hematocrit. Cyanosis occurs from a increased amount of deoxygenated blood.
A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response? A. "Earwax is made by glands in your ears." B. "More earwax is made when an infection is present." C. "To eliminate cerumen, flush the ears with water when you shower." D. "The amount of earwax lessens with aging."
Answer: A Rationale: Earwax or cerumen is made by specialized apocrine glands called ceruminous glands, which are found in the external ear where they produce cerumen or wax. There is no evidence that the amount of earwax lessens with aging. Flushing the ears with water when showering will not reduce the amount of cerumen produced. There is no evidence that cerumen increases when an infection is present.
A client has been diagnosed with liver disease. The nurse would expect which skin variation? A. Jaundice B. Pallor C. Cyanosis D. Ecchymosis
Answer: A Rationale: Jaundice occurs in liver or kidney disease. Cyanosis may occur with low oxygenation of the tissues. Ecchymosis occurs when there is trauma to the tissues. Pallor occur with anemia.
The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as: A. fissure. B. ulcer. C. scale. D. erosion.
Answer: A Rationale: Linear cracks in the skin are documented as fissures. Scales are flakes secondary to desquamated, dead epithelium. Erosions are defined as loss of superficial epidermis that does not extend into the dermis. Ulcers show skin loss that extends past the epidermis.
Which of the following pigments influences hair color? A. Melanin B. Sebum C. Keratin D. Pheromones
Answer: A Rationale: Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Sebum is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.
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? A. Patch test. B. Skin biopsy. C. Skin scrapings. D. Tzanck smear.
Answer: A Rationale: Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens, such as nickel or fragrances, to normal skin under occlusive patches. Patients wear these occluded strips on their backs for 48 hours, and the area is assessed after 72 hours.
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? A. Herpes zoster. B. Psoriasis. C. Fungal infection. D. Seborrheic dermatosis.
Answer: A Rationale: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined.
Which of the following could be a possible cause of cyanosis? A. Fever B. Low tissue oxygenation. C. Anemia D. Carbon monoxide poisoning.
Answer: B Rationale: A possible cause of cyanosis includes a low tissue oxygenation. A red appearance to the skin may be indicative of carbon monoxide poisoning. A pink color to the skin may be indicative of a fever or hypertension. Pallor occurs in anemia.
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? A. Macule B. Vesicle C. Papule D. Wheal
Answer: B Rationale: A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).
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? A. Concave B. Clubbing C. Brittle D. Discolored
Answer: B Rationale: Clubbing of the nails is evidenced by an angle greater than 160°, and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or "spooning" may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.
A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing? A. Scales B. Lichenification C. Atrophy D. Keloid
Answer: B Rationale: Lichenification is a thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? A. Orange-green B. Bronze C. Yellow D. Gray
Answer: B Rationale: Patients diagnosed with Addison's disease have a bronzed appearance, an "external tan." Yellowish skin is noted in the patient diagnosed with jaundice. Patients with renal failure may have a gray or orange-green cast to the skin.
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: A. Uremia. B. Liver dysfunction. C. Addison's disease. D. Carotenemia.
Answer: B Rationale: The appearance of a yellow color that first appears in sclera, the hard palate, and mucous membranes may be due to increased serum bilirubin concentration (>2.5 to 3 mg/L) due to liver dysfunction or hemolysis. Refer to Table 51-2 in the text.
The purpose of melanin is to: A. form a callus where the skin is subjected to friction. B. determine skin color. C. prevent drying and cracking of the skin and hair. D. assist in transfer of heat through contact.
Answer: B Rationale: The color of the skin is determined by a pigment called melanin, which is manufactured by melanocytes located in the epidermis. A callus is a thick layer of epidermal cells that forms in response to recurring friction on an area of skin. Conduction is the transfer of heat through contact. Sebum prevents drying and cracking of the skin and hair.
Which factor causes wrinkles among older adults? A. Decrease in estrogen production. B. Loss of subcutaneous tissue. C. Decrease in sebum. D. Decrease in melanin.
Answer: B Rationale: The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.
Which of the following actions helps the nurse to determine the quality of the skin turgor? A. Palpating the skin. B. Grasping the skin. C. Inspecting the palmar surface. D. Placing the dorsum of the hand on the surface of the skin.
Answer: B Rationale: The nurse determines the quality of the skin turgor by grasping the skin such as that over the sternum, between the thumb and forefinger. Normally the skin returns to its original position immediately after being released. Placing the dorsum of the hand on the surface of the skin helps in assessing the temperature. The nurse can detect moisture with the palmar surface, but the nurse cannot determine the quality of the skin by palpating.
Production of melanin is controlled by a hormone secreted by which of the following? A. Thyroid B. Hypothalamus C. Parathyroid D. Adrenal
Answer: B Rationale: The production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. Production of melanin is not controlled by the thyroid, adrenal, or parathyroid gland.
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? A. Dark discoloration of the skin. B. Yellowish waxy deposits on the eyelids. C. Liver spots. D. Bright red moles.
Answer: B Rationale: Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia. Solar lentigo refers to liver spots. Melasma refers to dark discoloration of the skin. Cherry angioma is the term used to describe a bright red mole.
Which diagnostic test is used to examine cells from herpes zoster? A. Skin scrapings B. Patch testing C. Tzanck smear D. Skin biopsy
Answer: C Rationale: A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scraping is used to diagnose spores and hyphae. A patch test is used to identify substances to which the client has developed an allergy.
Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? A. Pustule B. Erosion C. Spider angioma D. Cyst
Answer: C Rationale: A spider angioma is a vascular lesion. Erosion is a secondary lesion. Pustules and cysts are classified as primary skin lesions.
The nurse provides health teaching points to an adolescent about his skin. She reviews facts about hair growth and shaving. Which of the following sites has the slowest rate of growth? A. Scalp B. Axillae C. Eyebrows D. Thighs
Answer: C Rationale: Hair follicles undergo cycles of growth and rest. The rate of growth varies; beard growth is the most rapid, followed by hair on the scalp, axillae, thighs, and eyebrows.
A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas? A. Ear lobes B. Nail beds C. Sclerae D. Mucous membranes
Answer: C Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes. The term icterus is used to describe yellowing of the sclerae.
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? A. Notify the physician. B. Apply barrier cream. C. Document the finding. D. Turn and reposition the client.
Answer: C Rationale: Lesions that are red, papular, and round located on a client's trunk and blanch with pressure are typically cherry angiomas. Because this lesion has no clinical significance, the appropriate action by the nurse is to document the finding.
A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely? A. Wood's light examination B. Tzanck smear C. Patch testing D. Skin biopsy
Answer: C Rationale: Patch testing would be most likely for a patient with a history of allergies to identify substances that may be involved with the patient's allergy. A skin biopsy is done to rule out a malignancy and establish an exact diagnosis. Tzanck smear is used to examine cells from blistering skin conditions. Wood's light examination is used to differentiate epidermal from dermal lesions and hyperpigmented and hypopigmented lesions.
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present? A. The skin is dusky blue. B. The skin is reddish pink. C. The skin is ashen gray and dull. D. The skin is whitish pink.
Answer: C Rationale: Shock due to decreased perfusion and vasoconstriction is indicated in dark skin as an ashen gray, dull appearance.
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? A. Epidermis B. Stratum corneum C. Dermis D. Papillary layer
Answer: C Rationale: The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lies directly beneath the epidermis.
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? A. Circumscribed border. B. Flat with skin color change. C. Elevated and palpable. D. Greater than 1 cm in diameter.
Answer: C Rationale: The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, nonpalpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? A. "Have you been diagnosed with Addison's disease?" B. "Have you been in the sun a lot?" C. "Have you been eating a large number of carotene-rich foods?" D. "Have you been ingesting large quantities of alcohol?"
Answer: C Rationale: The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? A. Telangiectases B. Hirsutism C. Vitiligo D. Lichenification
Answer: C Rationale: Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.
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? A. Cyst B. Macule C. Vesicle D. Pustule
Answer: D Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss? A. Radiation B. Evaporation C. Convection D. Conduction
Answer: D Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.
To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? A. Sclera B. Nose C. Fingernails D. Oral mucosa
Answer: D Rationale: In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjunctivae, oral mucosa, and nail beds.
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? A. Cherry red face. B. Pallor. C. Bronzed appearance. D. Jaundice.
Answer: D Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin (>2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes.
The nurse recognizes which condition is associated with emboli to the skin? A. Spider angioma B. Ecchymosis C. Telangiectasia D. Petechiae
Answer: D Rationale: Petechiae are small, round red or purple macules and are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.
An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? A. Reduction in melanin production. B. Reduction in the elasticity of the skin. C. Reduction in estrogen production. D. Reduction in sebum production.
Answer: D Rationale: The sebum is a lubricant that prevents the drying and the cracking of the skin and hair. Due to aging, the skin becomes dry and flaked as sebum production is reduced. Loss of elasticity of the skin causes wrinkles among older adults. Reduction in melanin results in gray hair. Facial hair and sometimes chest hair appear in postmenopausal women as a result of the decreased production of estrogen.
A client is concerned about finding a few strands of hair on a pillow after sleeping and additional strands on the brush when styling the hair. Which response will the nurse make regarding the client's concern? A. "Losing hair means the hair follicles are dying." B. "That is an unusual amount and should be evaluated." C. "Most people who lose hair have an undiagnosed illness." D. "There are approximately 100 strands of hair lost per day."
Answer: D Rationale: Throughout a person's life, hair follicles undergo continuous cycles of growth, transition, and rest. The rate of growth varies and the hair follicle can be in a growth, involution, or resting phase. Approximately 5% to 10% of hair is in the resting phase when shedding occurs. A person will typically shed approximately 100 scalp hairs each day. Losing hair does not mean the hair follicle is dying. Finding hair strands on a pillow or brush is not unusual and does not need to be evaluated. Most people who lose hair do not have an undiagnosed illness.
Which term refers to yellowish waxy deposits on the upper and lower eyelids? A. Neurodermatitis B. Dyschromia C. Xerosis D. Xanthelasma
Answer: D Rationale: Xanthelasma is a yellowish waxy deposit on the upper and lower eyelids. Dyschromia refers to color variations. Neurodermatitis refers to itchy spots. Xerosis is dryness.
A client is having patch testing performed to identify allergies to substances. Which finding most concern the nurse? Select all that apply. A. Redness B. Papules C. Itching D. Pain E. Blisters
Answer: D, E Rationale: Patch testing involves applying allergens to normal skin under occlusive patches. The patches are worn on the back for 48 hours and the area is assessed after 72 hours. The development of pain and blisters indicates a strong positive reaction to the allergen, which would most concern the nurse. Itching and redness indicate a weak positive reaction. Papules indicate a moderately positive reaction.
