Chapter 64: Introduction to the Integumentary System (NCLEX Review Questions/PrepU)
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?
Dermis
A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections?
Diabetes
When planning the skin care of a client with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
The palms of the hands
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?
The skin is ashen gray and dull.
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?
Conduction
Which term describes the transfer of heat from the body to a cooler object in contact with it?
Conduction
While assessing a dark-skinned client at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis?
Vitiligo
A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next?
Assess the characteristics of the lesion.
A nurse in the emergency department (ED) is triaging a 5 year old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this client and her family?
"Has she eaten any new foods today?"
Which are true about fungal cultures? Select all that apply.
All statements are true.
The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?
An insect bite
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?
Beau's line
The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?
Biopsy
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?
Bronze
The nurse examines a client who slipped and fell while climbing stairs and now has swelling of one ankle, pain on movement, and localized ecchymosis. What word correlates with the nurse's use of the term "ecchymosis" when documenting the assessment data?
Bruised
The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
By palpating the client's skin
An unresponsive Caucasian client has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client's face is a cherry-red color. What should the nurse suspect?
Carbon monoxide poisoning
When the nurse identifies a client as being at risk for the development of a pressure sore, what nursing order is essential to add to the plan of care at this time?
Change client's position every 2 hours.
A client's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?
Disturbed Body Image
A client is diagnosed with atrial fibrillation and the physician orders warfarin. For what skin lesion should the nurse monitor this client?
Ecchymosis
The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding?
Hirsutism
A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.
Fingernails Hair Skin
What nursing assessment technique is best for determining the quality of the client's skin turgor?
Grasping a fold of skin over the sternum
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?
Herpes zoster
Which characteristics would be expected in a "within normal limit" skin assessment? Select all that apply.
Intact Warm Dry
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?
Keloid
Which factor causes wrinkles among older adults?
Loss of subcutaneous tissue
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?
Macule
While waiting to see the physician, a client shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the client is demonstrating what?
Macules
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?
Make sure that the room is darkened.
A new client has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. For what diagnostic test should the nurse prepare the client to identify the causative allergen?
Patch testing
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?
Patch testing
Which structure or process does not keep the body warm?
Respiration
A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?
Skin biopsy
A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component?
Subcutaneous tissue
A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?
Subcutaneous tissue
An older adult bedridden client frequently slides to the bottom of the bed with the feet touching the footboard. When the nurse analyzes the observation, what is the most likely outcome of the client's downward movement in bed?
The client is at risk for skin impairment because of shearing forces.
During a routine assessment, the nurse notes that a client's fingernails have a clubbed appearance. What is the nurse's most valid interpretation regarding this finding?
The client may have chronic cardiopulmonary disease.
When assessing a patient's skin, the nurse would use palpation to assess which of the following?
Turgor
A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?
Tzanck smear
Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
Ulcer
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?
Vesicle
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?
Vesicles
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of
anemia.
The nurse is caring for a client with herpes zoster. The nurse documents the lesions as
vesicles.