Skin Quiz
23-43: What would the help-line nurse advise a client who states that a skin lesion's color has changed, its size has increased, and its border is irregular? A. "Contact your primary health care provider immediately." B. "Continue to monitor the changes and take pictures to show your primary health care provider." C. "You should go to the nearest emergency department and have the lesion evaluated." D. "It may not be anything to worry about, but make an appointment within the next month."
A. "Contact your primary health care provider immediately."
23-30: Which is the nurse's best response when a client diagnosed with bedbug bites states he or she is embarrassed, showers every day, and lives in a clean environment? A. "Have you been traveling or staying in a hotel?" B. "No need for embarrassment, these things happen." C. "Showering will not kill bedbugs." D. "Have you seen bedbugs on your clothing?"
A. "Have you been travelling or staying in a hotel?"
22-29: Which teaching points would the nurse be sure to share with client scheduled for a punch biopsy? SATA A. A local anesthetic will be injected into the site B. A circular instrument will cut out a tissue sample C. The site will always require suturing after the procedure D. You will have a scar similar to a healed surgical incision E. Antibiotic ointment may be prescribed to reduce the risk for infection F. Keep a dry dressing on the site until your sutures are removed
A. A local anesthetic will be injected into the site B. A circular instrument will cut out a tissue sample E. Antibiotic ointment may be prescribed to reduce the risk for infection
23-2: Which clients would the nurse understand are at risk for pressure injuries? SATA A. A middle-aged quadriplegic client who is alert and conversant B. An ambulatory client who has occasional urinary incontinence C. A very thin client who sits for long periods in a chair and refuses meals D. An obese client who must be assisted to move and turn in bed E. An older adult who is bedridden and in late stage of Alzheimer's disease F. A client who is slightly confused but can use the bathroom with assistance
A. A middle-aged quadriplegic client who is alert and conversant C. A very thin client who sits for long periods in a chair and refuses meals D. An obese client who must be assisted to move and turn in bed E. An older adult who is bedridden and in late stage of Alzheimer's disease
23-19: Which priority nursing interventions focus on increasing client comfort and preventing skin injury when the client has pruritus? SATA A. Administering prescribed antihistamines or topical drugs B. Keeping client's fingernails trimmed short C. Instructing AP to trim toenails D. Applying mittens or gloves to client's hands at night E. Maintaining daily fluid intake of 3000 mL unless contraindicated F. After bathing, patting skin dry rather than rubbing
A. Administering prescribed antihistamines or topical drugs B. Keeping client's fingernails trimmed short D. Applying mittens or gloves to client's hands at night E. Maintaining daily fluid intake of 3000 mL unless contraindicated F. After bathing, patting skin dry rather than rubbing
22-17: When the nurse takes a client's medication history after noting the presence of ecchymoses, which types of drugs are of concern? SATA A. Aspirin products B. Oral antidiabetic agents C. Anticoagulants D. Long-term corticosteroids E. Histamine blockers F. Short-term loop diuretics
A. Aspirin products C. Anticoagulants D. Long-term corticosteroids
23-12: What would the nurse direct the home assistive personnel to do for an older adult client who wants to avoid dry skin? A. Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily) B. Generously apply oil and leave it on for 20 minutes; then bathe the client, especially the genital and axillary areas C. Use an antimicrobial skin soap and wash the client carefully; then apply alcohol-based astringent, especially to the legs and arms D. Use hot water with a deodorant soap; then gently pat the client dry and apply oil and cream to the skin
A. Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily)
23-42: Which preventive strategies for skin cancer would the nurse teach to clients and families? SATA A. Avoiding sun exposure between 11 am and 3 pm B. Wearing a hat, opaque clothing, and sunglasses when you are in the sun C. Using tanning beds no more than 30 minutes twice a week D. Taking pictures of lesions and comparing them month by month E. Keeping a "body map" of your skin spots, scars, and lesions F. Using sunscreens if your sun exposure will be more than an hour
A. Avoiding sun exposure between 11 am and 3 pm B. Wearing a hat, opaque clothing, and sunglasses when you are in the sun D. Taking pictures of lesions and comparing them month by month E. Keeping a "body map" of your skin spots, scars, and lesions
22-2: Which roles of a client's intact skin will the nurse consider most important? SATA A. Body temperature and regulation B. Protection against infection C. Providing nutrition to underlying cells D. Maintaining fluid and electrolyte balance E. Sensory function to provide comfort F. Aid in elimination of excess CO2
A. Body temperature regulation B. Protection against infection D. Maintaining fluid and electrolyte balance E. Sensory function to provide comfort
22-3: What is the most accurate method for the nurse to use when assessing cyanosis in a dark-skinned client admitted for pneumonia? A. Check the conjunctivae and nail beds for a bluish tinge color. B. Observe for asymmetrical skin color changes. C. Auscultate for decreased breath sound in the lung fields D. Inspect the palms and soles for a yellow-tinged color.
A. Check the conjunctivae and nail beds for a bluish tinge color.
23-45: Which client is most likely to be a candidate for Mohs surgery? A. Client with squamous cell carcinoma on the nose B. Client with joint contractures from burn injuries to the elbows C. Client with infected pressure injury in deep tissues over the coccyx D. Client with the need to have excessive breast tissue removed
A. Client with squamous cell carcinoma on the nose
22-21: Which assessment techniques would the nurse use when checking a client with dark skin for inflammation? SATA A. Compare affected area with nonaffected area for increased warmth B. Examine the nail beds, palms, and soles for blue tinge C. Compare the skin color of affected area with the same area on the opposite side D. Examine the sclera nearest to the iris rather than the corners of the eye E. Check the oral mucosa or conjunctive for petechiae F. Examine the skin of the affected area to see if it is shiny, taut, or pits with pressure
A. Compare affected area with nonaffected area for increased warmth C. Compare the skin color of affected area with the same area on the opposite side F. Examine the skin of the affected area to see if is shiny, taut, or pits with pressure
23-35: What is the priority focus of prehospital care for a client with a chemical injury burn? A. Decontamination B. Fluid balance C. Airway control D. Preventing infection
A. Decontamination
22-9: Which factors are included in the ABCDE features associated with skin cancer? SATA A. Evolving or changing of any feature B. Diameter greater than 5 mm C. Crusting, bleeding, or itching D. Color variation within a lesion E. Border regularity F. Asymmetry of shape
A. Evolving or changing of any feature D. Color variation within a lesion F. Asymmetry of shape
22-6: What is the best method for the nurse to complete a client's skin assessment while effectively using time management? A. Examine the client's skin while bathing or assisting with hygiene B. Perform the examination when the client willingly consents and agrees C. Question the assistive personnel who has completed the client's bath D. Check the skin assessment from the previous shift and look for changes
A. Examine the client's skin while bathing or assisting with hygiene
22-22: What does the nurse suspect when a client has skin that is tight and shiny over the lower extremities? A. Fluid retention and edema B. Early stage of infection C. Early signs of poor circulation D. Bleeding into the skin
A. Fluid retention and edema
22-16: Which actions would the nurse take when a client has decreased eccrine and apocrine gland activity? SATA A. Instruct the client to use soap with a high fat content B. Assess skin for size and shape of pores or comedones C. Use the oral mucosa to assess for cyanosis D. Teach the client to avoid frequent bathing with hot water E. Suggest wearing hats to prevent heat loss in cold weather F. Encourage the client to apply moisturizers after bathing
A. Instruct the client to use soap with a high fat content D. Teach the client to avoid frequent bathing with hot water F. Encourage the client to apply moisturizers after bathing
23-15: Which conditions will the nurse consider to be contributing factors for a client with chronic pressure injuries? SATA A. Malnutrition B. Peripheral vascular disease C. Incontinence D. Immobility E. Pressure relief mattresses F. Prolonged bedrest
A. Malnutrition B. Peripheral vascular disease C. Incontinence D. Immobility F. Prolonged bedrest
22-38: For which client will the nurse instruct the AP to use a lift sheet when assisting with movement in bed? A. Older adult client on steroids with thin, fragile skin B. Client with type 2 diabetes and delayed wound healing C. Obese client with moisture in skin folds D. Client with a substance use problem
A. Older adult client on steroids with thin, fragile skin
23-23: Which characteristics would the nurse expect to assess for a client with plaque psoriasis? SATA A. Raised, red patches covered with silvery white scales B. White pustules surrounded by reddened skin C. Affected areas usually include scalp, knees, elbows, lower back D. Usually starts after a streptococcal infection E. May be itchy, painful, or bleeding F. Affected areas usually include hands and feet
A. Raised, red patches covered with silvery white scales C. Affected areas usually include scalp, knees, elbows, lower back E. May be itchy, painful, or bleeding
22-7: Age-related changes in the integumentary system include decreases in which factors? SATA A. Rate of nail growth B. Thickness of epidermis C. Dermal blood flow D. Thickening of the nail E. Vitamin D production F. Epidermal permeability
A. Rate of nail growth B. Thickness of epidermis C. Dermal blood flow E. Vitamin D production
23-39: Which are priorities of care when providing care for a client with a burn injury during the emergent phase? SATA A. Securing the airway B. Maintaining nutrition status C. Supporting circulation & perfusion D. Maintaining body temperature E. Keeping client comfortable with analgesics F. Psychosocial adjustment
A. Securing the airway C. Supporting circulation & perfusion D. Maintaining body temperature E. Keeping client comfortable with analgesics
23-40: Which factors increase the risk of complications from a burn injury in an older adult client? SATA A. Slower healing time B. Thinner skin C. Increased inflammatory response D. Increased pulmonary compliance E. Medical conditions such as diabetes F. Increased immune response
A. Slower healing time B. Thinner skin E. Medical conditions such as diabetes
23-34: Which assessment findings would the emergency department nurse expect when a client has a smoke-related inhalation injury? SATA A,. Soot around the nose or mouth B. Singed nasal hairs C. Hoarseness of speech D. Shortness of breath E. Cherry red skin F. Cough
A. Soot around the nose or mouth B. Singed nasal hairs C. Hoarseness of speech D. Shortness of breath F. Cough
23-7: How will the nurse document assessment findings on a client's coccyx region that is reddened, is intact, and does not blanch when pressure is applied? A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Unstageable pressure injury
A. Stage 1 pressure injury
22-32: Which preprocedural teaching will the nurse provide for a client suspected of a bacterial cellulitis? A. The primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture B. The crusts will be removed with normal saline, then the underlying exudate will be swabbed for a specimen C. A smear will be obtained from the base of the lesion and examined in the lab under a microscope D. A cotton-tipped applicator will be used to obtain vesicle fluid from intact lesions
A. The primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture
23-25: In addition to topical drugs for psoriasis, which therapies would the nurse teach a client to reduce symptoms? SATA A. Ultraviolet irradiation B. Oral antibiotics C. Photochemotherapy with psoralen D. Surgical excision E. Excimer lasers F. Systemic therapy
A. Ultraviolet irradiation C. Photochemotherapy with psoralen E. Excimer lasers F. Systemic therapy
23-20: What would the nurse suspect when a client is admitted with a rash of white or red edematous papules or plaques that developed after the client ate seafood A. Urticaria B. Pruritis C. Eczema D. Psoriasis
A. Urticaria
23-4: Which technique would the nurse use to check for tunneling when assessing a large pressure injury on a client's hip with a small opening in the skin draining purulent material? A. Use a sterile cotton-tipped applicator to probe gently for the tunnel B. Using gloves, palpate the surface of the wound for spongy areas C. Flush the wound with sterile saline and watch the flow of the fluid D. Press around the edges of the wound and observe for erythema
A. Use a sterile cotton-tipped applicator to probe gently for the tunnel
23-5: Which interventions would the nurse use to prevent harm from development of a pressure injury in a client with a prolonged coma? SATA A. Use pillows or padding devices to keep the client's heels free from pressure B. When positioning a client on his or her side, position at a 30-degree tilt C. Use donut-shaped pillows under the coccyx when elevating the HOB 90 degrees D. Turn and reposition the client at least every 2 hours during all shifts E. Place pillows or foam wedges between two bony surfaces or between bony surfaces and the bed F. massage reddened areas to improve blood return and assist with healing
A. Use pillows or padding devices to keep the client's heels free from pressure B. When positioning a client on his or her side, position at a 30-degree tilt D. Turn and reposition the client at least every 2 hours during all shifts E. Place pillows or foam wedges between two bony surfaces or between bony surfaces and the bed
22-28: Which specimen would the nurse instruct the AP to immediately place on ice and transport to the lab as soon as possible? A. Vesicle fluid taken by sterile technique and placed in a viral culture tube B. Punch biopsy performed with sterile technique for collection of a tissue piece C. Exudate taken by sterile technique and swabbed on a bacterial culture medium D. Aspirate taken by sterile technique and placed in a bacterial culture tube
A. Vesicle fluid taken by sterile technique and placed in a viral culture tube
22-24: For which conditions, which could contribute to overall hygiene, would the nurse assess when a client for when the PHCP prescribes a test to determine if the client has a fungal infection of the skin? SATA A. Intact sensory functions B. Range of motion and strength C. Access to shower and laundry D. Client's currently prescribed drugs E. Perception of his or her appearance F. Knowledge (memory) of hygiene care
ALL of the above
23-26: Which actions would the nurse teach to a client and family to use to stop the spread of MRSA? SATA A. Wash your hands with soap and warm water before and after touching the infected area or handling the bandages B. Shower daily, using an antibacterial soap C. Sleep in a separate bed from others until the infection is cleared D. Do not share clothing, washcloths, towels, athletic equipment, shavers or razors, or any other personal items E. Avoid close contact with others, including participation in contact sports, until the infection has cleared F. Wash all soiled clothing and linens with hot water and laundry detergent. Dry clothing either in a hot dryer or outside on a clothesline in the sun
ALL of the above
22-14: Which questions would the nurse ask to determine if a client with a rash is having a new allergic reaction? SATA A. "Is your skin usually flaky or dry?" B. "Are you taking any new medications?" C. "Have you been using any different soaps, cosmetics, or lotions?" D. "Have you noticed any bruises or brownish discolorations?" E. "Have you been exposed to any new cleaning solutions?" F. "Have you had any recent changes in your diet?"
B. "Are you taking any new medications?" C. "Have you been using any different soaps, cosmetics, or lotions?" E. "Have you been exposed to any new cleaning solutions?" F. "Have you had any recent changes in your diet?"
23-21: Which question would the nurse ask a client, who has nonspecific eczematous dermatitis, to determine if avoidance therapy is an appropriate intervention? A. "Have you noticed a change in appearance of a mole?" B. "Have you used any new soaps, detergents, or personal care products?" C. "Does anyone residing in your household have a similar skin problem?" D. "Do you have a history of surgery for removal of skin growths?"
B. "Have you used any new soaps, detergents, or personal care products?"
23-28: Which information would the nurse teach a client about treatment of pediculosis pubis? A. Pubic lice are found only in the genital region of the body B. Abstain from sexual intercourse with any infected person C. Treatment of the condition involves shaving genital hair D. Over-the-counter lindane is a topical drug used to kill lice
B. Abstain from sexual intercourse with any infected person
23-14: Which finding, when assessing a client's wound for signs of healing or infection, indicates to the nurse that healing is progressing as expected? A. Wound surface is excessively moist with a deep reddish-purple color B. Area appears pale pink, progressing to a spongy texture with a beefy red color C. Eschar starts to lift and separate from the tissue beneath, which appears dry and pale D. Tissue is soft and more yellow with substantially increased exudates
B. Area appears pale pink, progressing to a spongy texture with a beefy red color
23-33: What priority complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs? A. Kidney failure B. Cardiac dysrhythmias C. Gastrointestinal ileus D. Fractured ribs
B. Cardiac dysrhythmias
23-17: Which client would the nurse monitor carefully when continuous negative-pressure wound therapy is used to facilitate healing? A. Client with diabetes mellitus B. Client receiving anticoagulation C. Client with severe pain D. Client hypertension
B. Client receiving anticoagulation
23-18: Which expected outcomes are appropriate for a client with a pressure injury? SATA A. Client will rate pain at an acceptable level B. Client will remain free from local or systemic infections C. Client will re-establish skin tissue integrity and restore skin barrier function D. Client will verbalize that wound is smaller E. Client's wound will show granulation and decrease in size F. Client will consume a diet rich in carbohydrates
B. Client will remain free from local or systemic infections C. Client will re-establish skin tissue integrity and restore skin barrier function E. Client's wound will show granulation and decrease in size
23-27: For which client would the nurse notify the primary health care provider when Zostavax vaccine for shingles is prescribed? A. Client with diabetes B. Client with immunosuppression C. Client with Raynaud's disease D. Client with hypertension
B. Client with immunosuppression
23-3: What collaborative action would the nurse take to promote wound healing for a thin, malnourished client who had emergency abdominal surgery? A. Encourage the client to be out of bed as soon as possible B. Consult with the registered dietician nutritionist about a high-protein diet C. Instruct the client about his or her caretaker about appropriate dressing changes D. Delegate complete morning care including a bed bath to the AP
B. Consult with the registered dietician nutritionist about a high-protein diet
22-13: When caring for an older adult, what skin change would cause the nurse to keep the client's room warmer? A. Decreased number of active melanocytes B. Decreased layer of subcutaneous fat C. Decreased thickness of epidermis D. Decreased sebum production
B. Decreased layer of subcutaneous fat
22-4: Which assessment technique would the nurse use to check the skin turgor of a client who is at risk for hypovolemia? A. Push on the skin with thumbs and observe for blanching B. Gently pinch the skin on the back of the hand and observe for tenting C. Brush the skin surface back and forth while observing for flaking D. Push on the skin over the tibia and observe for depth of indentation
B. Gently pinch the skin on the back of the hand and observe for tenting
22-20: Which technique does the nurse use to assess the "...health of the nails of a client with very dark skin." A. Obtain a color chart to identify the normal color of nails for dark-skinned clients B. Gently squeeze the end of the finger exerting downward pressure, then release it C. Observe the nail bed for a pale pink color and a shiny, smooth surface D. Soak the fingertips in warm water, then gently push back cuticles
B. Gently squeeze the end of the finger exerting downward pressure, then releasing it
23-38: Which is the best action for the nurse to take prior to changing the dressing of a client with a burn injury? A. Allow the client to rest and nap for an hour B. Give pain medication 30 minutes prior to dressing change C. Instruct the AP to give the client a complete bath D. Leave the wound open to air for 30 minutes
B. Give pain medication 30 minutes prior to dressing change
22-25: What diagnostic test does the nurse prepare a client for when the PHCP prescribes a test to determine if the client has a fungal infection of the skin? A. Punch biopsy B. KOH test C. Shave biopsy D. Wood's light exam
B. KOH test
23-41: Which client does the nurse consider to be at highest risk for the development of skin cancer? A. Dark-skinned male who works as a lab technician B. Light-skinned female who works as a lifeguard every summer C. Older adult who enjoys gardening and wears a large hat D. Younger adult who works at as a home health assistant
B. Light-skinned female who works as a lifeguard every summer
22-37: Which assessment finding does the nurse use as the best indicator of a client's healthy nails? A. Nail bed color is normal for the client B. Nail bed blanches with gentle pressure C. Nails are well groomed and nicely shaped D. Nail surface is smooth and transparent
B. Nail bed blanches with gentle pressure
23-36: Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries? SATA A. Hot water heaters should be set below 150 F B. Never add a flammable substance to an open flame C. Use sunscreen and protective clothes to avoid sunburn D. Avoid smoking when drinking alcohol or taking drugs that induce sleep E. When space heaters are used, keep flammable objects away from them F. If using home oxygen, do not smoke in the room where oxygen is in use
B. Never add a flammable substance to an open flame C. Use sunscreen and protective clothes to avoid sunburn D. Avoid smoking when drinking alcohol or taking drugs that induce sleep E. When space heaters are used, keep flammable objects away from them F. If using home oxygen, do not smoke in the room where oxygen is in use
23-11: How does the nurse determine which dressing is best for a client with a stage 3 pressure injury over the left trochanter area that has a thick exudate? A. Select a dressing that helps remove debris by mechanical debridement B. Obtain a prescription to consult with the certified wound care specialist C. Expect the primary health care provider to prescribe a drug for topical debridement D. Obtain a prescription for the type of dressing from primary health care provider
B. Obtain a prescription to consult with the certified wound care specialist
23-9: Which clients with pressure injuries would the nurse assess as at high risk for development of infection? SATA A. Client with rotator cuff injury awaiting surgery B. Older client with a low white blood cell count C. Client with type 1 diabetes mellitus D. Older client with high cholesterol who walks a mile every day E. Client with COPD on steroids F. Older client with large abdominal incision who needs help with repositioning
B. Older client with a low white blood cell count C. Client with type 1 diabetes mellitus E. Client with COPD on steroids F. Older client with large abdominal incision who needs help with repositioning
22-35: What changes in color does the nurse expect when assessing a client with polycythemia vera? SATA A. Brown localized skin areas B. Reddish blue generalized skin color C. Red color localized to area of involvement D. Dark red nail beds E. Diffuse blue discoloration of nails F. Yellow to brown nail beds
B. Reddish blue generalized skin color D. Dark red nail beds
22-19: Which is the best rationale for the nurse to use to encourage a client to seek treatment for dandruff? A. Dandruff is a cosmetic problem but appearance is important to self-esteem B. Severe dandruff is caused by excessive oiliness and can cause hair loss C. Dandruff flakes are caused by dry scalp and suggest possible dehydration D. Brushing your hair everyday can prevent dandruff but may weaken hair follicles
B. Severe dandruff is caused by excessive oiliness and can cause hair loss
22-34: Which areas would the nurse give special attention to when assessing an obese older adult? A. Mucous membranes B. Skinfolds C. Scalp D. Nails
B. Skinfolds
22-23: What priority instruction would the nurse provide the assistive personnel who is to bathe a client with skin that is not intact and is draining? A. Save any fingernail clippings or hair samples for testing B. Wear clean gloves and use Standard Precautions C. Have a second AP assist you to get the client out of bed D. Let the client soak in the tub for 15 minutes before rinsing
B. Wear clean gloves and use Standard Precautions
23-37: What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness? A. Place the client on continuous pulse oximetry B. Instruct the AP to check vital signs every 30 minutes C. Activate the Rapid Response Team D. Establish a second IV access
C. Activate the Rapid Response Team
23-22: Which essential teaching would the nurse provide for a client who is prescribed diphenhydramine to treat urticaria? A. Warm environments and warm showers will accelerate metabolism and recovery B. Use an emollient cream or lotion after bathing to reduce the itching C. Avoid alcohol consumption, which can potentiate the sedative effects of this drug D. Use an antibacterial soap when bathing and apply topical antibiotic cream after
C. Avoid alcohol consumption, which can potentiate the sedative effects of this drug
22-5: What is the best site for the nurse to assess skin for dehydration in an older adult client? A. Forearm B. Mid-thigh C. Forehead D. Lower abdomen
C. Forehead
23-31: What type of healing does the nurse assess when a client's surgical wound edges are approximated, closed with sutures, and there is no inflammation? A. Healing by third intention B. Healing by granulation C. Healing by first intention D. Healing by second intention
C. Healing by first intention
23-8: What would the nurse be sure to do before documenting a client's pressure injury changes with a series of photographs? A. Close the door and turn on the overhead light B. Pull the bedside curtains for client privacy C. Obtain informed consent from the client D. Consult with the primary health care provider
C. Obtain informed consent from the client
22-11: What area of a dark-skinned client would the nurse assess for petechiae when the client is at risk for thrombocytopenia? A. Palmar surface B. Anterior chest C. Oral mucosa D. Periorbital area
C. Oral mucosa
23-13: Which intervention would the nurse use to reduce shearing force for an obese client who is on bedrest for the next 3 days? A. Place the client in a high Fowler's position B. Instruct the client to use arms and legs to push when moving in bed C. Place the client in a side-lying position at a 30-degree tilt D. Assist the client to get up three to four times daily to a recliner chair
C. Place the client in a side-lying position at a 30-degree tilt
22-36: Which laboratory test would the nurse be sure to check when finding a large area of ecchymoses while assessing a client? A. Hemoglobin level B. White blood cell count C. Platelet count D. International normalized ratio (INR)
C. Platelet count
22-31: Which skin disorder is most associated with a familial predisposition? A. Scabies B. Cellulitis C. Psoriasis D. Ringworm
C. Psoriasis
23-29: Which condition would the nurse suspect when observing linear ridges on the inner aspects of the wrists and the client reports intense itching especially at night? A. Dermatitis B. Body lice C. Scabies D. Head lice
C. Scabies
22-26: What is the best place for the nurse to examine a fair-skinned client for yellow discoloration when jaundice is suspected? A. Palms B. Soles C. Sclera D. Nail beds
C. Sclera
22-12: For a decrease in which integumentary factor would the nurse avoid taping the skin on an older adult client? A. Vitamin D production B. Dermal blood flow C. Thickness of epidermis D. Melanocyte activity
C. Thickness of epidermis
23-1: Which medical-surgical concept would the nurse designate as the highest priority for a client with pressure injuries of both heels? A. Fluid and electrolyte balance B. Immunity C. Tissue integrity D. Cellular respiration
C. Tissue integrity
22-27: What is the best method for the nurse to collect a superficial specimen from a raised lesion for a suspected fungal infection in a client's groin? A. Express exudate from a lesion and use a sterile swab to collect fluid B. Obtain a small sample of tissue from the groin using needle biopsy C. Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen D. Have the PHCP do a deep excision with a scalpel followed by closure with sutures
C. Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen
23-16: When would the nurse expect to culture a client's pressure injury wound? A. Routinely every other day with a sterile culture swab B. When there is any exudate from the wound C. When clinical or systemic signs of infection are present D. When the pressure injury wound first becomes apparent
C. When clinical or systemic signs of infection are present
22-18: Which question would the nurse ask when assessing a female client who reports an unusual increase in facial hair? A. "Does your skin seem unusually dry and flakey?" B. "Have you noticed any bruising or unusual bleeding?" C. "Are you having trouble with urination or moving your bowels?" D. "Have you noticed any deepening of your voice?"
D. "Have you noticed any deepening of your voice?"
22-10: When regulating body temperature, how much evaporative water can the eccrine sweat glands lose in one day? A. 500-600 mL/day B. 700-900 mL/day C. 2-4 L/day D. 10-12 L/day
D. 10-12 L/day
23-32: How long would the nurse expect client's partial-thickness wound to heal by epithelialization? A. 24 hours B. 48 hours C. 2-3 days D. 5-7 days
D. 5-7 days
23-10: Which finding indicating infection in a client would the nurse report to the health care provider immediately? A. Progressive decrease in injury size and depth B. Presence of granulation and re-epithelialization C. Beefy red color that grows and fills in the wound D. Changes in the quantity, color, or odor of exudate
D. Changes in the quantity, color, or odor of exudate
23-6: Which instruction would the nurse give the AP about how to perform skin care on a client at risk for pressure injury because of immobility and incontinence? A. Use an antibiotic soap and rinse with hot water to remove all soap residue B. Scrub vigorously to ensure that all dried feces are removed C. After cleaning, apply a light layer of powder or talc directly on the perineum D. Clean the skin and moisturize with dimethazone, zinc oxide, lanolin, or petrolatum
D. Clean the skin and moisturize with dimethazone, zinc oxide, lanolin, or petrolatum
22-39: Which term would the nurse use to document a client's skin lesions that are widespread involving most of the body? A. Circumscribed B. Universal C. Linear D. Diffuse
D. Diffuse
22-40: Which terms would the nurse use to document a client's rash that is red, raised, and itching over most of his or her body? A. Red, macular, lichenified B. Cyanotic, annular, popular C. Red, universal, circinate D. Erythematous, diffuse, pruritic
D. Erythematous, diffuse, pruritic
23-46: What is the priority action for the nurse and other interprofessional team members when caring for a client with Stevens-Johnson syndrome? A. Treat the subjective symptoms of pain and itching B. Closely observe for signs of renal failure C. Protect against localized skin infection D. Identify the offending drug and discontinue it
D. Identify the offending drug and discontinue it
22-8: Which skin changes does the nurse expect to see in an older adult client as a result of a decreased number of active melanocytes? A. Increased skin transparency B. Decreased skin firmness and elasticity C. Slowed and decreased healing D. Increased sensitivity to sun exposure
D. Increased sensitivity to sun exposure
22-15: Which skin assessment finding in an older adult client is most important for the nurse to report to the PHCP for follow-up? A. Presence of cherry hemangiomas B. Multiple brownish liver spots on the arms C. Dry and flaky skin on the lower extremities D. Irregular light-brown macule (6.5 cm) on the right scapula
D. Irregular light-brown macule (6.5 cm) on the right scapula
23-44: Which finding when the nurse assesses a nevus on a client's back would be of concern and warrant further investigation? A. Regular and well-defined borders B. Uniform dark brown color C. Rough surface D. Report of itching and bleeding
D. Report of itching and bleeding
23-24: Which essential teaching would the nurse provide for a younger female client with psoriasis who is prescribed tazarotene? A. This drug can reduce the effectiveness of hormone-based contraceptives B. Tazarotene should be applied to each lesion for only a short period of time C. This drug can help relieve chronic psoriasis but may cause acne D. Tazarotene can cause birth defects even when applied topically
D. Tazarotene can cause birth defects even when applied topically
22-1: What is the priority medical/surgical concept when the nurse assesses a client and finds reddened scratch marks on the right forearm? A. Infection B. Immunity C. Cellular regulation D. Tissue integrity
D. Tissue integrity
22-33: What skin manifestations does the nurse expect to observe in a client during impending shock? A. Dry, flushed appearance B. Poor turgor with a rough texture C. Bluish color that blanches D. White, pale, cool skin
D. White, pale, cool skin
22-30: Which equipment would the nurse obtain to assist the PHCP in examining a light-skinned client for evaluation of skin pigment changes? A. Glass slides B. Biopsy tray C. Bright non fluorescent light D. Wood's lamp
D. Wood's lamp