Med Surg 1, Exam 2: Ch. 22 & 23 - Integumentary System & Problems

(23) 7. The nurse notes white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"

a. "Are you taking any medications?" The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection.

MR 2. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/VN)? (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. Administer patch testing to a patient with allergic dermatitis. c. Apply a sterile dressing after the health care provider excises a mole. Skills such as administration of patch testing and sterile dressing technique are included in LPN/VN education and scope of practice. Obtaining a health history and patient education require registered nurse (RN) level education and scope of practice.

(23) 6. Which instructions should the nurse include in the teaching plan for a patient with impetigo? a. Clean the crusted areas with soap and water. b. Spread alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

a. Clean the crusted areas with soap and water. The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions.

(23) 17. A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."

b. "If the medication burns when I apply it, I will wipe it off." The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective.

(23) 9. The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. Which statement should the nurse include in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because of the risk for infection caused by chemotherapy."

b. "Your cheek area will be eroded and take several weeks to heal." Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea.

7. 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.

b. Assess the patient for evidence of liver disease. 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 first action should be further assessment.

(23) MR1. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? (Select all that apply.) a. Add oil to your bath water to moisturize the affected skin. b. Cool, wet clothes or compresses can be used to reduce itching. c. Use an over-the-counter (OTC) antihistamine to reduce itching. d. Take cool or tepid baths several times daily to decrease itching. e. Rub yourself dry with a towel after bathing to prevent skin maceration.

b. Cool, wet clothes or compresses can be used to reduce itching. c. Use an over-the-counter (OTC) antihistamine to reduce itching. d. Take cool or tepid baths several times daily to decrease itching. Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.

(23) 25. 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. Method of contraception used by the patient 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.

(23) 5. A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned with blue eyes. d. The patient's mother died of malignant melanoma.

b. The patient uses a tanning booth weekly. Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma.

10. A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should 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

b. Thickening of the skin around the ankles Lichenification is likely to occur in areas where the patient scratches the skin often. It 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 because of scratching the skin.

(23) 24 There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 42-yr-old with itching after using topical fluorouracil on the nose b. 50-yr-old with skin redness after having a chemical peel 3 days ago c. 38-year old with a 7-mm nevus on the face that has recently become darker d. 62-yr-old with multiple small, soft, pedunculated papules in both axillary areas

c. 38-year old with a 7-mm nevus on the face that has recently become darker The description of the lesion is consistent with possible malignant melanoma. The health care provider should assess this patient as soon as possible. Itching is common after using topical fluorouracil, and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife.

(23) 14. What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.

c. Wash hands and properly dispose of soiled dressings. Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection to others. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.

(23) 21. A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of taking part in an online support group. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.

d. Ask the patient to describe the impact of psoriasis on quality of life. The nurse's initial actions should be to assess the impact of the disease on the patient's life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate.

9. 5. 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

b. Symmetric 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.

(23) 4. A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

a. Prepare the patient for a skin biopsy. Because the appearance of the lesion is suggestive of actinic keratosis or possible squamous cell carcinoma, the appropriate treatment would be excision and biopsy. Over-the-counter corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion.

(23) 22. The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

a. The patient recently had an intrauterine device removed. Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use.

(23) 10. A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected area c. Dryness and scaling in the area d. Reddish-brown skin discoloration

a. Thinning of the affected skin Thinning of the skin indicates atrophy, a possible adverse effect of topical corticosteroids. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness and scaling of the skin are not adverse effects of topical corticosteroid use.

(23) 2. Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance d. Wear sunglasses to avoid eye damage while taking this medication.

a. Use a sunscreen with a high SPF when exposed to the sun. The patient should stay out of the sun. If that is not possible, teach the patient to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate.

3. 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. Press firmly on the lesion. 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.

2. 1. Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be 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

b. Reports a history of allergic rashes 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.

5. A patient with dark skin has been admitted to the hospital with acute decompensated 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. Check the lips and oral mucous membranes. Cyanosis persons with dark skin is more easily seen in the mucous membranes. Earlobe color may change in persons with light skin, but this change in skin color is hard to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color.

1. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.

c. Consult with the health care provider about the need for further diagnostic testing. The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.

6. 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. Cotton-tipped applicators Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection or aspiration is not involved in the procedure. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens.

8. 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. Incisional biopsy An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be cancerous. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

(23) 3. Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low-dose systemic chemotherapy is used to treat BCC.

c. Minimizing sun exposure reduces risk for future BCC. BCC is frequently associated with sun exposure, and preventive measures should be taken for future sun exposure. BCC spreads locally and does not metastasize to distant tissues. Because BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.

(23) 8. A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Red, hivelike papules and plaques with circumscribed borders c. Papular, wheal-like lesions with white deposits on the hair shaft d. Patchy areas of alopecia with small vesicles and excoriated areas

c. Papular, wheal-like lesions with white deposits on the hair shaft Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.

11. Which abnormality on the skin of an older patient is the priority for the nurse to discuss 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. Petechiae on the chest and abdomen Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

4. The home health nurse notices irregular patterns of bruising at different stages of healing on an older 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. Suggest that the health care provider prescribe radiographs.

c. Talk with the patient alone and ask about the bruising. The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. Radiographs may be needed if the patient has fallen recently and reports pain or decreased mobility. However, the nurse's first nursing action is to further assess the

(23) 18. The nurse teaches a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

c. The patient applies a thick layer of the cream to the affected skin. Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful.

(23) 20. The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient reports incisional pain. b. The patient's heart rate is 100 beats/min. c. The skin around the incision is pale and cold. d. The patient is unable to sense touch on the eyelids.

c. The skin around the incision is pale and cold. Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 100 beats/min may be related to the stress associated with surgery. Assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.

(23) 1. Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Water-resistant sunscreens provide good protection when swimming. c. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.

c. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.

13. Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.

c. Use warm water and a moisturizing soap when bathing. Warm water and moisturizing soap will avoid over drying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.

12. 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. Ask the patient about a personal or family history of type 2 diabetes. The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patient's skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better.

(23) 19. The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap

d. Cleaning the skin with antimicrobial soap Cleaning the skin is within the education and scope of practice for UAP. Administering medication, obtaining cultures, and evaluation are higher level skills that require the education and scope of practice of licensed nursing personnel.

MR 1. 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. Erythema e. Actinic keratosis A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure.

(23) 11. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.

d. Have the patient use protective eyewear while receiving PUVA. The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.

(23) 12. A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision

d. Surgical excision The description of the mole is consistent with cancer, so excision and biopsy are indicated. Curettage and cryosurgery are not used if cancer is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter.

(23) 16. An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Schedule daily appointments for dressing changes. b. Describe the use of topical fluorouracil on the incision. c. Instruct how to use sterile technique to clean the suture line. d. Teach the use of cold packs to reduce bruising and swelling.

d. Teach the use of cold packs to reduce bruising and swelling. Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Because the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure, the edges of the wound can be left open to heal, or the edges can be approximated and sutured together. The suture line can be cleaned with tap water. No daily dressing changes are indicated after the first dressing is removed.

(23) 15. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient takes diphenhydramine at night for persistent itching. d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.

d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions. Neosporin can cause contact dermatitis. The patient is appropriately using the other medications.