ch 22

When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? a. Increased bruising b. Excess perspiration c. Decreased extracellular fluid d. Decreased peripheral blood supply

c

Persons with dark skin are more likely to develop a. keloids b. wrinkles c. skin rashes d. skin cancer

a

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair

ANS: B Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient

A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Whichof the following information should the nurse include in the teaching? (Select all that apply.) A. Bathe with antibacterial soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover affected area with snug fitting clothing. E. Allow lesions to dry before applying topical medication.

a,c,e

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin.

What is the most common diagnostic test used to determine a causative agent of skin infections? a. Culture b. Tzanck test c. Immunofluorescent studiesd . Potassium hydroxide (KOH) slides

a

the patient is visiting a free clinic to refill her medications. during the generalized assessment, the nurse documents alopecia; an increased heart rate; warm, moist, flushed skin; and thin nails. the patient also states she is anxious and has lost weight lately. which systemic problem will the nurse most likely suspect and relate to the health care provider. a. hyperthyroidism b. systemic lups erthymatosus c. vitamin B1 deficiency d. human immunodeficiency virus (HIV) infection

a

A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. Which of thefollowing client statements indicates a need for further teaching? A. "I can expect redness around the site for 3 days." B. "I will call my doctor if I have a fever." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 7 days for removal of my sutures."

a

The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals b. papules c. pustules d. plaques

a

To assess the skin for temperature and moisture, the most appropriate technique for the RN is to use is: A. palpation B. inspection C. percussion D. auscultation

a

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is a. thickening of the skin .b. dermatitis in the folds of her skin. c. loss of color in diffuse areas of her skin. d. a firm plaque caused by fluid in the dermis.

b

A patient has a plaque lesion on the dorsal forearm. Which type of biopsy is most likely to be used for diagnosis of the lesion? a. Punch biopsy b. Shave biopsy c. Incisional biopsy d. Excisional biopsy

b

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo

b

The nurse observes that redness remains after palpation of a discolored lesion on the patient's leg. This finding is characteristic of a. varicosities. b. intradermal bleeding. c. dilated blood vessels. d. erythematous lesions.

b

The patient asks the nurse what telangiectasia looks like. Which is the best description for the nurse to give the patient? a. A circumscribed, flat discoloration b. Small, superficial, dilated blood vessels c. Benign tumor of blood or lymph vessels d. Tiny purple spots resulting from tiny hemorrhages

b

The primary function of the skin is a. insulation b. protection c. sensation d. absorption

b

diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained b. a more definitive diagnosis is needed c. percussion reveals an abnormal finding d. treatment with prescribed medication has failed

b

A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face

b Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable contraception has the most potential for serious adverse medication effects.

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

c

A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratoryfindings should the nurse anticipate reviewing to confirm this diagnosis? A. Potassium hydroxide (KOH) B. Culture and sensitivity C. Tzanck smear report D. Biopsy

c

A nurse is providing teaching to a client about a new prescription for clotrimazole (Lotrimin). Which ofthe following should the nurse include in the teaching? A. "It reduces the discomfort of a herpetic infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks." D. "Allow the area to remain moist before applying."

c

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

c

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Syringe and intradermal needle

c

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Notify the health care provider so that radiographs can be ordered.

c

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face

c

during the physical examination of a pateint's skin, the nurse would a. us a flashlight in a poorly lit room b. note cool, moist skin as a normal finding c. pinch up a fold of skin to assess for turgor d. perform a lesion specific examination first and then a general inspection

c

on inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. this assessment finding call a. vitiligo b. intertrigo c.nevus of ota d. telangiectasia

c

Priority Decision: When performing a physical assessment of the skin, what should the nurse do first? a. Palpate the temperature of the skin with the fingertips. b. Assess the degree of turgor by pinching the skin on the forearm. c. Inspect specific lesions before performing a general examination of the skin. d. Ask the patient to undress completely so all areas of the skin can be inspected.

d

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.

d

What is the primary difference between an excoriation and an ulcer? a. Ulcers do not penetrate below the epidermal junction. b. Excoriations involve only thinning of the epidermis and dermis .c. Excoriations will form crusts or scabs whereas ulcers remain open. d. An excoriation heals without scarring because the dermis is not involved.

d

When obtaining important health information from a patient during assessment of the skin, it is important for the nurse to ask about a. a history of freckles as a child. b. patterns of weight gain and loss. c. communicable childhood illnesses. d. skin problems related to the use of medications.

d

The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

d,e

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.

ANS: B Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent b. Symmetric c. Zosteriform d. Generalized

ANS: B The description of the lesions indicates that they are grouped in a bilateral distribution. The other terms are inconsistent with the description of the lesions.

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.

a,c

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

b If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg but will not be helpful in determining the etiology of the lesion.

A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpesinfection. Which of the following actions should the nurse take? (Select all that apply.) A. Scrape the site with a wooden tongue depressor. B. Puncture the crusted area with a sterile needle. C. Swab the crusted area with a sterile cotton-tipped applicator. D. Place cotton-tipped applicator in culturette tube. E. Place culturette tube in ice.

b,d,e

age-related changes in the hair and nails include (SATA) a. oily scalp b. scaly scalp c. thinner nails d. thicker, brittle nails e. longitudinal nail ridging

b,d,e

when assessing an african american patient, the nurse notes ashen color of the nail beds. what should the nurse do next a. palpate for rashes on the legs b. assess for jaundice in the sclera of the eye c. assess the mucous membranes for cyanosis d. assess for pallor of the skin on the buttocks

c

when assessing the nutritional- metabolic pattern in relation to the skin, the nurse questions the patient regarding a. joint pain b. the use of moisturizing shampoo c. recent changes in wound healing d. self-care habits related to daily hygiene

c