CH 55: Assessment of Integumentary Function

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? A) Patch B) Macule C) Plaque D) Papule

B

The diagnosis of a skin disorder is made chiefly by which of the following? A) Biopsy B) Visual inspection C) Palpation D) Culture

B

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? A) Wheal B) Vesicle C) Papule D) Macule

B

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) Discolored B) Clubbing C) Concave D) Brittle

B

Sudoriferous glands secrete which type of substance? A) Sweat B) Oil C) Hormones D) Cerumen

A

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as? A) Keloid B) Atrophy C) Lichenification D) Scar

A

Which of the following actions helps the nurse to determine the quality of the skin turgor? A) Grasping the skin B) Placing the dorsum of the hand on the surface of the skin C) Palpating the skin D) Inspecting the palmar surface

A

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? A) Fungal infection B) Iron deficiency anemia C) Long-standing cardiopulmonary disease D) Poor circulation

B

The purpose of melanin is to: A) assist in transfer of heat through contact. B) determine skin color. C) form a callus where the skin is subjected to friction. D) prevent drying and cracking of the skin and hair.

B

Which diagnostic test is used to examine cells from herpes zoster? A) Skin scrapings B) Tzanck smear C) Skin biopsy D) Patch testing

B

Which layer of the skin is made of primarily adipose tissue? A) Epidermis B) Hypodermis C) Muscle D) Dermis

B

Which of the following pigments influences hair color? A) Keratin B) Melanin C) Sebum D) Pheromones

B

The nurse is having difficulty seeing a client's rash. Which action(s) should the nurse perform to facilitate the assessment? Select all that apply. A) Pull the skin downward. B) Stretch the skin gently. C) Point a penlight laterally across the affected part. D) Apply an emollient.

B and C

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) trapping debris in the external ear C) prevents drying and cracking of the skin and hair D) cooling overwarm skin

C

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 ingesting large quantities of alcohol?" B) "Have you been diagnosed with Addison's disease?" C) "Have you been eating a large amount of carotene-rich foods?" D) "Have you been in the sun a lot?"

C

Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate? A) Thighs B) Eyebrows C) Beard D) Axillae

C

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced? A) Evaporation B) Radiation C) Conduction D) Convection

C

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding? A) Alopecia B) Hyperpigmentation C) Hirsutism D) Jaundice

C

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? A) Seborrheic dermatosis B) Psoriasis C) Herpes zoster D) Fungal infection

C

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

D

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? A) Lichenification B)Hirsutism C) Telangiectases D) Vitiligo

D

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) Crust D) Scar

A

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high? A) Evaporation B) Conduction C) Radiation D) Convection

A

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? A) Bronze B) Orange-green C) Gray D) Yellow

A

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) Lichenification B) Scales C) Keloid D) Atrophy

A

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) Dermis B) Papillary layer C) Stratum corneum D) Epidermis

A

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) Spider angioma B) Erosion C) Pustule D) Cyst

A

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) Elevated and palpable B) Flat with skin color change C) Circumscribed border D) Greater than 1 cm in diameter

A

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) Yellowish waxy deposits on the eyelids B) Dark discoloration of the skin C) Bright red moles D) Liver spots

A

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? A) Petechiae B) Telangiectasias C) Ecchymoses D) Cherry angiomas

A

Which of the following describes a total absence of pigment melanin? A) Albinism B) Vitiligo C) Cyanosis D) Anemia

A

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is a symptom of what? A) Vitiligo B) Sjogren's syndrome C) Jaundice D) Addison's disease

A

Which of the following is a strong positive reaction to patch testing? Select all that apply. A) Blisters B) Pain C) Redness D) Ulceration E) Itching

A, B, and D

The nurse is preparing a teaching tool on the functions of the skin. Which information about the skin will the nurse include on this tool? Select all that apply. A) Protects the body from microorganisms B) Supplies oxygen to the underlying tissues C) Serves as a sensory organ D) Aids in maintaining fluid balance E) Helps regulate body temperature

A, C, D, and E

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client? A) The client should consider changing careers as stress plays a significant role in this condition. B) Recommend the client speaks with a health care provider about currettage which is the most common treatment. C) Avoidance of direct sunlight with protective clothing measures should be discussed with the client. D) Reassure the client that the condition usually resolves if dietary restrictions limiting caffeine and alcohol are followed.

C

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) Skin biopsy B) Skin scrapings C) Patch test D) Tzanck smear

C

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? A) Local trauma B) Anemia C) Hypoxia D) Psoriasis

C

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? A) Itchy spots B) Dryness C) Freckles D) Yellowish waxy deposits

C

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 estrogen production C) Reduction in sebum production D) Reduction in the elasticity of the skin

C

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) Sebum deficiency B) Protein deficiency C) Fluid retention D) Dehydration

C

Production of melanin is controlled by a hormone secreted by which of the following? A) Thyroid B) Parathyroid C) Hypothalamus D) Adrenal

C

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 whitish pink. B) The skin is reddish pink. C) The skin is ashen gray and dull. D) The skin is dusky blue.

C

The nurse is caring for an adult patient with a normal body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient? A) 1,000 mL/day B) 250 mL/day C) 600 mL/day D) 800 mL/day

C

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? A) Nose B) Fingernails C) Oral mucosa D) Sclera

C

Which secondary skin lesions are associated with eczema? A) Ulcers B) Scales C) Crusts D) Erosion

C

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. A) Endocrine glands B) Subcutaneous tissue C) Fingernails D) Skin E) Hair

C, D, and E

A nurse is performing a skin assessment on a client with diabetes and notes furuncles and carbuncles to both lower legs. The client states their skin typically has "issues" but eventually heals if left alone. Which of the targeted teaching topics would most benefit this client? A) Discuss treatment options for kaposi sarcoma, topical skin treatments, weight control measures, and adherence. B) Review of altered integumentary function related to diabetes, managing dermatophyte infections, and dietary restrictions. C) Review signs and symptoms of fungal infections, short acting insulin management, and wound debridement measures. D) Discuss treatment concerning bacterial infections, blood glucose levels, and basic skin maintenance techniques.

D

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) Bronzed appearance B) Pallor C) Cherry red face D) Jaundice

D

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 spider angioma that is associated with liver disease. B) It is a telangiectasia that is associated with varicose veins. C) It is an ecchymosis that is associated with trauma and bleeding. D) It is a cherry angioma that is a normal age-related skin alteration.

D

Petechiae are associated with which of the following disorders? A) Deep vein thrombosis B) Pulmonary emboli C) Acute respiratory distress syndrome (ARDS) D) Thrombocytopenia

D

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following? A) Cicatrix B) Lichenification C) Nodule D) Keloid

D

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) Obtain samples of the lesion by scraping. B) Protect the patient from the light. C) Apply a special dye to the area. D) Make sure that the room is darkened.

D

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) Thighs B) Axillae C) Scalp D) Eyebrows

D

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding? A) Pearly white substance that is attached to the hair shaft that is not removed with brushing B) Sparse hair, white in color C) Knots in hair when brushed D) Dry, brittle hair

A

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) "To eliminate cerumen, flush the ears with water when you shower." B) "Earwax is made by glands in your ears." C) "More earwax is made when an infection is present." D) "The amount of earwax lessens with aging."

B

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) "That is an unusual amount and should be evaluated." B) "There are approximately 100 strands of hair lost per day." C) "Most people who lose hair have an undiagnosed illness." D) "Losing hair means the hair follicles are dying."

B

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) Turn and reposition the client. B) Document the finding. C) Apply barrier cream. D) Notify the physician.

B

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as A) spider angioma. B) petechiae. C) ecchymosis. D) telangiectasia.

B