test 1 AGPCNP1-Integumentary

Caroline has a 13-year-old daughter who has had 2 recent infestations of lice. She asks you what she can do to prevent this. You respond:

"Don't let her share hats, combs, or brushes with anyone."

Marge, age 36, is planning to go skiing with her fiancé. He has warned her about frostbite, and she is wondering what to do if frostbite should occur. You know she's misunderstood the directions when she tells you which of the following?

"I should rub the area with snow." Rubbing or massaging the frostbitten area, especially with snow, may cause permanent tissue damage.

You're teaching Mitch, age 18, about his tinea pedis. You know he doesn't understand your directions when he tells you which of the following?

"I should wear rubber shoes in the shower to prevent transmission to others." Rubber- or plastic-soled shoes can harbor the fungus and therefore should not be worn. The shower should be washed with bleach to kill the fungi.

Deanna, age 6, was bitten by a friend's dog. Her mother asks you if the child needs antirabies treatment. You tell her:

"If the dog is a domestic pet that has been vaccinated, the wound should be cleaned and irrigated." If the dog is a domestic pet that has been vaccinated, the wound should be washed thoroughly with soap and water and then treated like any other wound.

Susan states that her fiancé has been frostbitten on the nose while skiing and is fearful that it will happen again. What do you tell her?

"Infarction and necrosis of the affected tissue can happen with repeated frostbite." Permanent tissue damage can occur with a second episode of frostbite involving the same skin surface.

Client teaching is an integral part of successfully treating pediculosis. Which of the following statements would you incorporate into your teaching plan?

"Itching may continue for up to a week after successful treatment." Client education is essential when treating pediculosis. Clients should be informed that itching may continue for up to a week after successful treatment because of the slow resolution of the inflammatory reaction caused by the lice infestation.

Ashley, age 6 months, has a Candida infection in the diaper area. What do you suggest to the parent?

"Keep the area as dry as possible." Clients must be taught to decrease favorable environmental conditions for Candida (eg, moisture, warmth, and poor air circulation).

Your 24-year-old client whose varicella rash just erupted yesterday asks you when she can go back to work. What do you tell her?

"Once all the vesicles are crusted over." A client who has a varicella rash can return to work once all the vesicles are crusted over. Varicella is contagious 48 hours before the onset of the vesicular rash, during the rash formation (usually 4-5 days), and during the several days it takes the vesicles to dry up. The characteristic rash appears 2 to 3 weeks after exposure.

Dermatophyte skin infections can be diagnosed from skin scrapings and prepared with which solution for microscopic exam?

10% or 20% potassium hydroxide (KOH) solution. Under microscopic exam, fungal scrapings in potassium hydroxide (KOH) solution will appear as threadlike hyphae crossing cell walls. The other solutions are not indicated to identify dermatophytes.

A patient complaining of hyperhidrosis should be counseled that:

A history and physical exam need to be completed to rule out any medical etiologies. Excessive sweating may be normal, but a history and physical exam are needed to rule out underlying causes. Therapies can be offered. Drysol is for use only on the feet and axilla.

In performing a skin assessment, the adult-gerontology primary care NP understands that the following characteristic of a mole would necessitate immediate intervention:

A new, 5-6-mm brown mole with an irregular red border that is occasionally pruritic. The appearance of a new mole with high-risk features, including irregular border, color changes, and changes in sensation (e.g., pruritus), would necessitate immediate biopsy and/or referral to a dermatologist. Uniform moles, those that are symmetric and have smooth borders, and those not showing signs of change can be followed with annual skin assessments. Seborrheic keratosis is a benign skin growth, usually on sun-exposed areas, and appearing as waxy or "stuck-on" that requires no treatment.

Which of the following patients would not be at risk of Candida infection?

A patient with a history of coronary artery disease.

The nurse practitioner (NP) tells Samantha, age 52, that she has an acrochordon on her neck. What is the NP referring to?

A skin tag. Skin tags (acrochordons) are benign overgrowths of skin commonly seen after middle age and usually found on the neck, axillae, groin, upper trunk, and eyelids.

Maryann, age 28, presents to the clinic because of a rapid onset of patchy hair loss. The skin within these oval patches of hair loss is very smooth. Tapered hairs that resemble exclamation points are seen at the margin of a patch of hair loss. Based on these findings, you suspect Maryann has:

Alopecia areata. The findings are consistent with alopecia areata, ie, nonscarring hair loss of rapid onset, the pattern of which is most commonly sharply defined round or oval patches.

A Gram stain of a lesion reveals large, square-ended, gram-positive rods that grow easily on blood agar. Which diagnosis does this finding confirm?

Anthrax. Anthrax is diagnosed with a Gram stain revealing large, square-ended, gram-positive rods that grow easily on blood agar.

Jill, age 29, has numerous transient lesions that come and go, and she is diagnosed with urticaria. What do you order?

Antihistamines. Transient urticaria requires antihistamines on a regular basis.

The ABCDEs of melanoma identification include which of the following?

Asymmetry: one half does not match the other half. A is for asymmetry: one half does not match the other half. One of the warning signs of cancer is a lesion that does not heal or an area that changes in appearance. The ABCDEs of melanoma identification should be taught to all clients.

What is the most important thing a person can do to maintain healthy skin and hopefully reduce wrinkles?

Avoid smoking. The most important thing a person can do to maintain healthy skin is not smoke. Smokers develop more wrinkles and have elastosis, decreased tissue perfusion and oxygenation, and an adverse exposure to free radicals on elastic tissue.

Which skin cancer that arises from skin cells, characteristically occurs on body areas exposed to the sun, most commonly presents as a pearly nodule with fine telangiectasias over the surface and a border that appears rolled, and is the most common skin cancer?

Basal cell carcinoma. Basal cell carcinoma arises from skin cells and is the most common type of nonmelanoma skin cancer (greater than 80%).

Sandra, age 69, is complaining of dry skin. What do you advise her to do?

Bathe or shower with lukewarm water and use a mild soap or skin cleanser. If a client is complaining of dry skin, the client should use tepid water and a mild cleansing cream or soap.

A circumscribed, elevated lesion >1 cm in diameter and containing clear serous fluid is best described as a:

Bulla Bulla is the correct term. A papule is solid. A vesicle is <1 cm in diameter, and a pustule contains a purulent exudate.

Shelby, age 14, has a blister on her arm that is filled with clear fluid. It is the result of contact with a hot iron. How do you document this?

Bulla. A bulla is a primary skin lesion that is filled with fluid and larger than 1 cm in diameter. It is also known as a vesicle.

Mildred, age 72, presents to the clinic with a blistering rash that is generalized but located mostly in skin folds and on flexural areas. She describes the course of the rash as beginning with pruritic urticarial papules that coalesced into plaques that turned dark red in about 2 weeks, followed by the development of vesicles and bullae. She tells you that the lesions are moderate to severely pruritic. During your exam, you determine the bullae are very tense and do not rupture when pressure is applied. Her daily medications include an angiotensin-converting enzyme (ACE) inhibitor, a loop diuretic, and a nonsteroidal anti-inflammatory drug (NSAID). What is your diagnosis?

Bullous pemphigoid. Most cases of bullous pemphigoid occur after 60 years of age. The bullae are very tense; firm pressure on the blisters will not result in extension into the normal skin, which occurs with pemphigus vulgaris.

A middle-aged male patient presents to the clinic with a complaint of being bitten last night by another individual during a fight. He has a bite mark on his forearm, and the skin has been broken. He reports he does not remember any recent vaccinations for tetanus. Recommended treatment by the adult-gerontology primary care NP should include all the following except:

Close the wound with sutures or Nexcare Steri-Strips Delay wound closure until determination of no infection in approximately 24-48 hours. Mouth flora of humans is abundant, and a bite carries the risk of heavy bacterial inoculum and severe infection. Antibiotics are indicated. A Td booster should be given every 10 years. Tdap may be given as one of these boosters if the patient has never received Tdap before. Typically, one dose of Tdap is routinely given at age 11 or 12 years. People who did not get Tdap at that age should get it as soon as possible. Tdap may also be given after a severe cut or burn to prevent tetanus infection.

When palpating the skin over the clavicle of Norman, age 84, you notice tenting, which is:

Common in thin older adults. Tenting—which occurs when pinched skin remains pinched for a few moments before resuming its normal position—over the clavicle is common in thin older adults. Skin turgor is decreased with dehydration and increased with edema and scleroderma.

A 16-year-old male presents to your office. He was sent by an orthopedist. He has recently had surgical fixation of a humerus fracture. The patient has been going to physical therapy and has been developing a rash on his arm after therapy that disappears shortly after returning home. He does not have the rash prior to therapy. The patient denies fevers and chills, and his incision is well healed, with no signs of infection. Of note, the patient has been experiencing more hand edema than the average patient and has had edema wraps used at the end of therapy to help with his swelling. The wraps are made of a synthetic plastic material. The rash the patient gets is erythematous and blotchy, not raised; it is on the operative upper extremity. What is the most likely diagnosis?

Contact dermatitis. The patient's history and rash are consistent with a latex or plastic sensitivity due to the edema wraps used in therapy.

Which presentation is most concerning for skin cancer?

Dark pigmentation of 1 solitary nail that has developed quickly and without trauma.

Tom, age 50, is complaining of an itchy rash that occurred about a half hour after putting on his leather jacket. He recalls having a slightly similar rash last year when he wore his jacket. The annular lesions are on his neck and both arms. They are erythematous, sharply circumscribed, and both flat and elevated. His voice seems a little raspy, although he states that his breathing is normal. What is your first action?

Determine the need for 0.5 mL 1:1000 epinephrine subcutaneously. Tom has hives. Although all the actions are appropriate, the first step is to determine the need for 0.5 mL 1:1000 epinephrine subcutaneously. With Tom's neck involvement, it is most important to determine if respiratory distress is imminent; if it is, epinephrine must be administered.

You are examining Barbara, age 27, who presents with multiple dry, dusky red, well-localized plaques with a "stuck-on" appearance. They are 5 to 20 mm in diameter and located on her face, scalp, and external ears. You note there is atrophy, telangiectasia, depigmentation, and follicular plugging present. On examination of the scalp, there are areas of total hair loss. There is depigmented scarring of the concha of the ear. Your most likely diagnosis is:

Discoid lupus erythematosus. The lesions of discoid lupus erythematosus are dry and have a stuck-on appearance, which differentiates them from seborrheic dermatitis and psoriasis. Old lesions that have caused scarring further distinguish these lesions from seborrheic dermatitis, psoriasis, and tinea capitis. Depigmented scarring of the concha of the ear is a classic finding.

A middle-aged patient presents for an office visit with a complaint of a measles-like rash on his trunk and spreading to his extremities. He was seen several days ago for bronchitis and started on trimethoprim-sulfamethoxazole (TMP-SMX; Septra) ds 1 tab PO bid. What is the recommended action for the adult-gerontology primary care NP?

Discontinue TMP-SMX. In case of suspected drug reactions, it is recommended that the drug be eliminated and documented in the patient's record so that it is not reintroduced.

In making a differential diagnosis between nummular eczema (dermatitis) and dyshidrotic eczematous dermatitis, the adult-gerontology primary care NP knows:

Dyshidrotic eczematous dermatitis is a chronic vesicular type of hand-and-foot eczema characterized by vesicles (tapioca-like), scaling, lichenification, and pruritus. Despite the name "dyshidrotic" eczematous dermatitis (bullous form called pompholyx), there is no evidence of sweating. Most patients have an atopic history, and emotional stress is often a precipitating factor in the appearance of the vesicles. Nummular (discoid) eczema is a chronic, pruritic, inflammatory dermatitis that occurs as coin-shaped plaques composed of papules and vesicles on an erythematous base. Rosacea is characterized by flushing and clusters of papulopustules on the cheek and forehead. Psoriasis is a hereditary disorder characterized by chronic, usually bilateral scaly plaques on exposed areas (knees, elbows). A verruca or common wart affects primarily young adults, is contagious, and is characterized by firm papules with a cleft surface and multiple conical vegetations.

Which of the following has/have been linked to the use of isotretinoin?

Elevated liver transaminases Depression, psychosis, and suicidality. Benign intracranial hypertension.

Which disease usually starts on the cheeks and spreads to the arms and trunk?

Erythema infectiosum (fifth disease). Erythema infectiosum (fifth disease) usually starts on the cheeks and spreads to the arms and trunk.

Helen, age 39, comes to your clinic for generalized joint pain, especially in the knees and hands. She tells you that the pain is moderate, spreading, and symmetrical. She reports having had a sore throat and low-grade fever for a few days and then developing a rash, described as warm erythema of the cheeks, which lasted about 4 days before disappearing. You ask her if the rash on the cheeks included the nasolabial folds or circumoral skin, and she tells you that it did not cover these areas. Two days later, she developed a nonspecific macular eruption that preceded the joint pain. Her rash faded within 2 weeks, but she tells you that it comes and goes if she bathes in hot water or spends time in the sunlight. Your patient's symptoms are most consistent with a diagnosis of:

Erythema infectiosum. Erythema infectiosum (fifth disease) is distinguished by its erythematous, warm rash, which gives the appearance of "slapped cheeks," and it does not involve the nasolabial folds or the circumoral region. Women are more likely to have joint pain as a symptom of erythema infectiosum.

A mother complains that her newborn infant, while lying on his side, appears red on the dependent side of the body and pale on the upper side. When she picks up the baby, this coloring disappears. You explain to her about which of the following?

Harlequin sign. The harlequin sign is a transient phenomenon in a newborn who has been lying on one side. The dependent side is red while the upper side is pale, as if a line has been drawn down the middle of the body. This disappears when the infant's position is changed.

Dan, age 57, has just been given a diagnosis of herpes zoster. He asks you about exposure to others. You tell him:

He should stay away from children and pregnant women who have not had chickenpox.

In a burn trauma, which blood measurement rises as a secondary result of hemoconcentration when fluid shifts from the intravascular compartment?

Hematocrit. In burn trauma, the hematocrit rises as fluid, not blood, shifts from the intravascular compartment.

An older adult woman has an area of vesicles in clusters with an erythematous base that extend from her spine, around and under her arm and breast, to the sternum on her left side. She states that the area was very tender last week and that the vesicles started erupting yesterday. She is complaining of severe pain in the area. What is the probable diagnosis for this condition?

Herpes zoster Herpes zoster typically presents with a history of tenderness followed by eruptions and vesicles that follow a dermatome on one side of the body. The condition is very painful. Other symptoms may include fever, headaches, and malaise. Psoriasis is characterized by thick, white, silvery, or red patches of skin. Contact dermatitis is a rash caused by touching something. Cellulitis is a skin infection characterized as red, hot, swollen, and tender skin.

A patient complains of intolerable itching in the pubic hair. On exam, the adult-gerontology primary care NP notes erythematous papules and tiny white specks in the pubic hair. The differential diagnosis includes all except:

Impetigo Intense itching is characteristic of pediculosis pubis, scabies, and atopic dermatitis. Impetigo starts out as a tender erythematous papule and progresses through a vesicular to a honey-crusted stage with no itching.

Which is a true statement about psoriasis?

It can be aggravated by stress. Stress can aggravate psoriasis. Sunlight helps psoriasis, so it is usually better in the summer. It is not contagious, and only about 30% of patients with psoriasis have pruritus.

A patient known to be positive for HIV presents with several painless, persistent, raised purple lesions on the lower arm. What is the most likely diagnosis of the lesions?

Kaposi sarcoma Although any of these conditions can affect the skin, particularly of a patient who is HIV-positive, the description relates most closely to Kaposi sarcoma and warrants a biopsy.

Lee brings her 13-year-old son to your clinic. He has been complaining of a rash on the buttocks, anterior thighs, and posterolateral aspects of his upper arms. He tells you it is mildly pruritic and looks like "gooseflesh." On examination, the rash appears as small, pinpoint, follicular papules on a mildly erythematous base. You explain to Lee that the benign condition is likely to resolve by the time her son reaches adulthood, and it is known as:

Keratosis pilaris. The description and examination of this rash are consistent with keratosis pilaris, which most commonly appears on the cheeks, buttocks, anterior thighs, and posterolateral aspects of the upper arms.

The following are all true statements regarding urticaria except:

Laboratory studies are necessary to identify the causative agent. Laboratory studies are not likely to be helpful in evaluation of urticaria. Identification of causes is usually based on history and physical findings. The other statements are true of urticaria.

Eric, age 52, has gout. What do you suggest?

Limiting consumption of purine-rich foods. For a client with gout, the consumption of purine-rich foods, such as organ meats, should be limited to prevent uric acid buildup.

The adult-gerontology primary care NP is assessing an older patient diagnosed with herpes zoster (shingles) in the prodromal stage. What would the practitioner expect to find on the assessment of this patient?

Linear burning pain in a line on only half the patient's chest that does not cross the midline. Herpes zoster (shingles) is a vesicular dermatomal eruption related to a reactivation of latent varicella virus. It increases with advanced age and is characterized by burning pain and paresthesia along one or two dermatomes, not crossing the midline, and may be accompanied by fever, malaise, or headache. The vesicular stage lasts 2-3 weeks. The vesicles are initially clear or blood filled and become purulent. The area along the dermatome is erythematous, and the vesicles crust and then scab, which may leave hypopigmented scars. The other options discuss painless lesions and are not specific to this prodromal stage.

A biopsy of a small, yellow-orange papulonodule on the eyelid will probably show:

Lipid-laden cells. A biopsy of a small, yellow-orange papulonodule on the eyelid will probably show lipid-laden cells. This is a description of a noneruptive xanthoma of the eyelid (xanthelasma).

A 3-year-old patient presents to your pediatric office with her mother. She has recently been started in day care. Her mother noted slight perioral erythema on the right side of the patient's mouth prior to bed last night. The patient awoke today with 3 small, superficial, honey-colored vesicles where the erythema was last night. The patient has no surrounding erythema. She had no difficulty eating this morning and is active and energetic and doesn't appear lethargic or fatigued. She is also afebrile. How would you treat this child?

Local debridement and mupirocin for 5 days.

On exam of a patient's skin, the adult-gerontology primary care NP finds a lesion that is about 0.75 cm in diameter, brown, circumscribed, flat, and nonpalpable. What is the correct term for this lesion?

Macule A macule is less than 1 cm in diameter, nonpalpable, flat, and brown, red, purple, or tan (freckles, flat moles, rubella). A papule is elevated and palpable (warts, pigmented nevi). A nodule is 1-2 cm in diameter, solid, elevated, and deeper (lipoma). A wheal is elevated and irregular and has a variable diameter (insect bites, urticaria).

Nail involvement secondary to primary foot-and-hand tinea, characterized by accumulation of subungual keratin that produces thickened, distorted, crumbling nails, is termed:

Onychomycosis Onychomycosis is the correct term. Hippocratic nails are clubbed nails and fingers associated with chronic heart and lung disorders. Koilonychia is a concavity of the nail plate often associated with iron-deficiency anemia. Anonychia is a total congenital absence of the nail.

A 70-year-old client with herpes zoster has a vesicle on the tip of the nose. This may indicate:

Ophthalmic zoster. Ophthalmic zoster (herpes zoster ophthalmicus) involves the ciliary body and may appear clinically as vesicles on the tip of the nose. A client with a herpetic lesion on the nose needs to be referred to an ophthalmologist to preserve the eyesight.

What finding would indicate to the adult-gerontology primary care NP that an immunoglobulin E-mediated potential trigger was suspected in the presence of an adult patient who had acute urticaria?

Patient had eaten seafood salad that day. Urticaria arising from immunoglobulin E-mediated potential trigger could occur from food sensitivity/allergen exposure. Water intake and temperature elevations would be associated with nonimmunologically mediated causes. Flulike symptoms would be associated with non-immunoglobulin E-mediated causes due to presence of viral infection.

Clubbing of the nails commonly occurs in patients with chronic respiratory conditions. The adult-gerontology primary care NP assesses for this condition by:

Placing nail beds of each index finger together to determine angle of nail plate. The angle between the nail plate and the proximal nail fold when viewed from the side is >180 degrees and should form a diamond in clubbed nails. Normal nails form a 160-degree angle and should form a diamond shape between them when the nail beds of the index fingers are placed together. Transverse ridges and grooves may occur from trauma. Placing the palms together provides no assessment data. Diffuse discoloration may result from a fungal infection or an injury.

A 70-year-old female presents to the clinic complaining of pain on her left arm. Inspection of the extremity reveals no erythema. Her skin is intact with no evidence of lesions. The patient's past medical history includes herpes zoster. Which clinical diagnosis would the adult-gerontology primary care NP make as supported by this patient's presentation and past medical history?

Postherpetic neuralgia A potential complication that can occur following activation of herpes zoster virus with an acute episode is the chronic progression to that of postherpetic neuralgia. Unlike with acute presentations, there is no evidence of customary lesions associated with shingles leading patients to present with pain presentations classified as allodynia. Phantom pain presents in patients with an amputation. Although most elderly patients present with atypical symptoms in the presence of urinary tract infections, on the basis of this patient's past medical history, it is more likely that she is experiencing a complication of herpes zoster. Tinea infection would present with a skin lesion finding.

The Wood lamp may be used to evaluate skin lesions. When the light is shone on the patient's skin, a green-yellow fluorescence indicates:

Presence of fungi Fungal lesions will be visualized as a green-yellow fluorescence when viewed with the Wood lamp in a dimly lit room.

Mr. Swanson, age 67, presents to the clinic for his annual health exam. He asks you if there is anything he can do to prevent the painful, blistering sores that develop on his lip in the summertime when he plays golf. You explain to Mr. Swanson that the way to prevent the development of these lesions is to:

Protect the lips from sun exposure with a blocking agent, such as zinc oxide, or a lip balm that contains a broad-spectrum sunscreen. Mr. Swanson has recurrent herpes simplex virus type 1 (HSV-1), ie, orolabial herpes. Factors that trigger reactivation include local skin trauma, sunlight exposure, and systemic changes, such as menses, fatigue, and fever. In this question, the clinician is teaching prevention. Protecting the lips from sun exposure is a preventive measure.

A 64-year-old female patient presents with an erythematous area of skin on her left buttock. She states that it is painful because it is located along her bikini line. She is worried she may not be able to continue to relax in the hot tub at her apartment community in the evenings. She denies any recent injuries to the area. Which of the following should the adult-gerontology primary care NP suspect as the most likely cause?

Pseudomonas aeruginosa Hot tub folliculitis caused by Pseudomonas aeruginosa should be suspected in any patient presenting with folliculitis and recent exposure to hot tubs. The infected area is most often in an area where wet clothing causes extended close contact with infected water. Staphylococcus should be suspected in patients without a known exposure or risk factor because it is the most common cause of folliculitis overall.

A 22-year-old college student presents to your urgent care clinic complaining of a rash. She was recently on spring break and spent every night in the hot tub at her hotel. On physical exam, she has multiple small areas of 1- to 2-mm erythematous pustules that are present mostly where her bathing suit covered her buttocks. What is the most likely pathogen causing these lesions?

Pseudomonas aeruginosa. This is a common cause of hot tub folliculitis.

What is a chronic skin condition that is sometimes associated with arthritis?

Psoriasis Approximately 10%-30% of people with psoriasis develop an accompanying form of arthritis called psoriatic arthritis. The other options are dermatologic conditions that are not directly associated with arthritis.

Jim, age 59, presents with recurrent, sharply circumscribed red papules and plaques with powdery white scale on the extensor aspects of his elbows and knees. What do you suspect?

Psoriasis. If a client presents with recurrent, sharply circumscribed red papules and plaques with powdery white scale on the extensor aspects of his elbows and knees, suspect psoriasis. This is a classic presentation of psoriasis. Besides the extensor aspects of the elbows and knees, it occurs frequently in the presacral area and scalp, although lesions may occur anywhere.

Which statements about psoriasis are true?

Psoriatic lesions are often silvery scales that form over erythematous plaques. People with psoriasis have a greater risk of depression than the average population. Psoriasis has a genetic component.

You suspect a platelet abnormality in a 40-year-old woman who presents to your clinic with:

Red, flat, nonblanchable petechiae. A client with a platelet abnormality may present with red, flat, nonblanchable petechiae.

A 65-year-old presents to the clinic for evaluation of small rough areas on his face that have increased in size over the past year. He states that he had several similar lesions on his neck removed a few years ago. Physical examination reveals 1 cm × 1 cm areas of erythematous, sandpaper-like lesions that are yellow to light brown in color above his brow. No discharge is noted. Which of the following should the adult-gerontology primary care NP educate the patient regarding lesions of this type?

Risk of squamous cell carcinoma These lesions are most likely actinic keratosis. Actinic keratosis is a premalignant lesion at high risk of developing into squamous cell carcinoma of the skin. Actinic keratosis is most likely seen in sun-exposed areas and is described as a sandpaper-like lesion of a yellow to light brown coloration that may be erythematous. The patient should be referred to a dermatologist for further evaluation and removal of the lesion.

During a camping trip, Jim, age 35, abruptly developed fever, headache, and joint pain. A few days after the onset of the fever, a blanchable macular rash began on his wrists and ankles and quickly spread to the palms and soles before becoming generalized. The rash is now petechial. You suspect Jim has:

Rocky Mountain spotted fever. A macular rash of the wrists and ankles that is followed by spread to the palms and soles before then becoming petechial is a characteristic finding of Rocky Mountain spotted fever.

The history and physical of a patient indicates past occurrences of lichenification. The adult-gerontology primary care NP identifies the characteristics of this lesion as:

Rough, thickened epidermis, accentuated skin markings. Lichenification occurs with chronic irritation, often of an exposed extremity (chronic dermatitis). Crusts are dried exudate; scales are heaps of keratinized cells from exfoliation (psoriasis); and loss of epidermis is excoriation, as seen in an abrasion.

During the physical exam, the adult-gerontology primary care NP assesses a maculopapular skin lesion on a patient's back that is warty, scaly, greasy in appearance, and light tan in color. What would be the probable diagnosis?

Seborrheic keratosis The assessment describes a seborrheic keratosis. The actinic keratosis is an irregular, rough, scaly, white-to-erythematous macular lesion found most often on sun-exposed areas, such as on the dorsal surface of the hands, arms, neck, and face. It has malignant potential. The basal cell carcinoma is a smooth, round nodule with a pearly gray border and central induration. Senile lentigines are gray-brown, irregular, macular lesions on sun-exposed areas of the face, arms, and hands.

Which human papillomavirus serotypes most commonly cause cancer?

Serotypes 16 and 18.

A 55-year-old landscaper presents to your primary care office complaining of a small skin lesion on his face. The patient states the lesion causes no pain or other symptoms. On physical exam, you notice a small (3 mm) papule that is flesh-colored and irregular. To palpation, the lesion feels hard and like sandpaper. What type of malignancy is this patient at risk for given the appearance of this lesion?

Squamous cell carcinoma. The lesion described is an actinic keratosis, which is a premalignant lesion that can progress to squamous cell carcinoma.

Sophie brings in her husband, Nathan, age 72, who is in a wheelchair. On his sacral area, he has a deep crater with full-thickness skin loss. Subcutaneous tissue is visible but muscle and bone are not. Which pressure ulcer stage is this?

Stage III. A stage III pressure ulcer is one that has a deep crater with full-thickness skin loss. Subcutaneous tissue may be visible; however, underlying structures, such as tendon, muscle, and bone, are not visible. There may be undermining or tunneling. Keep in mind that in areas with little or no subcutaneous tissue, such as the heel or bridge of the nose, stage III ulcers may be shallow.

Roy, age 13, was recently diagnosed with epilepsy and prescribed carbamazepine for control of his seizures. He has developed erythematous papules, dusky appearing vesicles, purpura, and target lesions that have erupted rapidly and are more centrally distributed on the face. He has hemorrhagic crusts on his lips. He tells you his skin feels tender and burns. Additionally, he has developed exudative conjunctivitis. These findings are indicative of:

Stevens-Johnson syndrome (SJS). SJS is a severe blistering mucocutaneous syndrome that involves at least 2 mucous membranes. Drugs frequently implicated in the development of SJS are phenytoin, phenobarbital, carbamazepine, sulfonamides, and aminopenicillins.

Martin, age 13, just started taking amoxicillin for otitis media. His mother said that he woke up this morning with a rash on his trunk. What is your first action?

Stop the amoxicillin.

Which of the following should be used with all acne medications?

Sunscreen

A dark-field microscopic examination is used to diagnose:

Syphilis. A dark-field microscopic examination is used to diagnose syphilis. With its special condenser, a dark-field microscope causes an oblique beam of light to refract off objects too small to be seen by conventional microscopes, such as the narrow organism (Treponema pallidum) that causes syphilis.

Sandra, age 32, comes in to the clinic. She has painful joints and a distinctive rash in a butterfly distribution on her face. The rash has red papules and plaques with a fine scale. What do you suspect?

Systemic lupus erythematosus. If a client comes in to the clinic complaining of painful joints and has a distinctive rash on the face that consists of red papules and plaques with a fine scale in a butterfly distribution, suspect systemic lupus erythematosus. Acute lupus erythematosus occurs most often in young adult women. In the acute phase, the client is febrile and ill. The presence of these skin lesions in a client with neurological disease, arthritis, renal disease, or neuropsychiatric disturbances also supports the diagnosis.

When administering skin tests to an immunocompromised patient, the adult-gerontology primary care NP must consider:

The practice of using positive and negative control solutions. It is important to remember to apply controls when skin testing the immunocompromised patient. A positive control test (histamine dichloride solution) is used to determine whether the patient reacts to histamine. If there is not an immediate reaction to histamine, the results of allergy skin tests can be difficult to interpret. A negative control test contains a solution (glycerinated saline) that does not contain histamine or allergen. If a reaction occurs, the skin is too sensitive to allow for correct interpretation of allergy skin tests.

Which of the following statements about malignant melanomas is true?

The prognosis is directly related to the thickness of the lesion.

What information should be provided to a patient with actinic keratosis?

These lesions can develop into squamous cell carcinomas. Actinic keratoses are potentially precancerous lesions that are commonly found in areas of skin exposed to sunlight

Buddy, age 13, presents with annular lesions with scaly borders and central clearing on his trunk. What do you suspect?

Tinea corporis. Psoriasis, erythema multiforme, tinea corporis, and syphilis all have lesions with annular configurations. Tinea corporis (ringworm) has ring-shaped lesions with scaly borders and central clearing or scaly patches with distinct borders on exposed skin surfaces or on the trunk.

Danny, age 18, presents with a pruritic rash on his upper trunk and shoulders. You observe flat to slightly elevated brown papules and plaques that scale when they are rubbed. You also note areas of hypopigmentation. What is your initial diagnosis?

Tinea versicolor. If a client presents with a pruritic rash on his upper trunk and shoulders and you observe areas of hypopigmentation and flat to slightly elevated brown papules and plaques that scale when they are rubbed, suspect tinea versicolor.

Jennifer, age 32, is pregnant and has genital warts (condylomata) and would like to have them treated. What should you order?

Trichloroacetic acid. Genital warts (condylomata) may be treated using liquid nitrogen cryotherapy, trichloroacetic acid, or podophyllin (Podocon-25). However, podophyllin is contraindicated in pregnancy.

A 27-year-old female comes in to your primary care office complaining of a perioral rash. The patient noticed burning around her lips a couple days ago that quickly went away. She awoke from sleep yesterday and noticed a group of vesicles with erythematous bases where the burning had been before. There is no burning today. She is afebrile and has no difficulty eating or swallowing. What test would confirm her diagnosis?

Tzanck smear. This would show giant cells consistent with herpes simplex virus.

Louis, age 52, presents with pruritus with no rash present. He has hypertension, diabetes, and end-stage renal disease (ESRD). Which of the following would be included in the differential diagnosis?

Uremia from chronic renal disease. All of the conditions listed result in pruritus. However, only uremia from chronic renal disease results in pruritus with no rash present. The other conditions—contact dermatitis, lichen planus, and psoriasis—all present with a rash.

A 22-year-old African American female presents to your family practice office complaining of progressive skin discoloration. She is adopted and has no known family history of skin problems. The patient notes nonpalpable patches of skin loss and blanching of her forehead and both hands and feet. It has developed over a period of 6 months and appears to have stopped. It is not pruritic, and there is no erythema or sign of infectious etiology. What is the most likely diagnosis?

Vitiligo.

Stage IV pressure ulcer

involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. In a stage IV pressure ulcer, underlying structures are visible or directly palpable.

Stage I pressure ulcer

is nonblanchable erythema of intact skin.

Androgenetic alopecia

is premature loss of hair in an androgen-sensitive area of the scalp; in men, it is commonly known as male-pattern baldness.

Stage II pressure ulcer

partial-thickness skin loss involving the epidermis and/or dermis. It may appear as an abrasion, blister, or shallow ulcer.

An eczematous skin reaction may result from:

penicillin. Penicillin, neomycin, phenothiazines, and local anesthetics may cause an eczematous type of skin reaction.