Chapter 60: Assessment of Integumentary Function

An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many "spots" on her skin. What would be an appropriate response by the nurse?A) As people age, they normally develop uneven pigmentation in their skin. B)These 'spots' are called 'liver spots' or 'age spots.' C)Older skin is more apt to break down and tear, causing sores. D)These are usually the result of nutritional deficits earlier in life.

"Ans: A Feedback: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the son's question. These lesions are not normally a result of nutritional imbalances.

A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?A) Does anyone in your family have eczema or psoriasis? B)Have any of your family members been diagnosed with malignant melanoma? C)Do you have a family history of vitiligo or port-wine stains? D) Does any member of your family have a history of keloid scarring?

"Does anyone in your family have eczema or psoriasis?"

A nurse in 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 patient and her family?A) Has she eaten any new foods today? B) Has she bathed in the past 24 hours? C) Did she go to a friend's house today? D) Was she digging in the dirt today?

"Has she eaten any new foods today?"

While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what? Macules

A macule is a flat, nonpalpable skin color change

A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? A)Crust B)Keloid C)Pustule D)Ulcer

A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin.

A patient with human immunodeficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what?A) A reduction in the patient's CD4 count B)A reduction in the patient's viral load C)An adverse effect of antiretroviral therapy D)Virus-induced changes in allergy status

A reduction in the patient's CD4 count

A patient 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?A) Tzanck smear B)Skin biopsy C)Patch testing D)Skin scrapings

A skin biopsy is done to rule out malignancies of skin lesions.

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?

A wheal is a primary skin lesion that is elevated and has fluid contained in the dermis. An example of a wheal would be an insect bite or hives.

A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?A) Skin biopsy B)Patch test C) Tzanck smear D)Examination with a Wood's light

The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus.

Assessment of a patient'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?A)Keloid B)Ulcer C)Fissure D)Erosion

An ulcer is skin loss extending past the epidermis with the involvement of necrotic tissue.

The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?A) Cherry angiomas B) Solar lentigo C) Seborrheickeratoses D) Xanthelasma

Ans: A Feedback: Cherry angiomas appear as bright red moles, while solar lentigo are commonly called liver spots. Seborrheickeratoses are described as crusty brown stuck on patches, while xanthelasma appears as yellowish, waxy deposits on the upper eyelids.

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A) By avoiding the use of moisturizing lotions on older adults' skin B)By protecting older adults against shearing injuries C)By avoiding the use of ice packs to treat muscle pain D)By protecting older adults against excessive sweat accumulation

Ans: B Feedback: Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults' skin. Ice packs can be used, provided skin is assessed regularly and the patient possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient? A) Ulcer B)Ecchymosis C)Scar D)Erosion

Ans: B Feedback: Ecchymosis refers to a round or irregular macular lesion, which is larger than petechiae. This occurs secondary to blood extravasation. It is important to watch for ecchymosis in a patient receiving any type of anticoagulant. An ulcer is an open lesion eroded into the patient's flesh. A scar is an area on the skin caused by the healing of an injury. Erosion is loss of superficial epidermis that does not extend to the dermisa depressed, moist area.

student is brought to the nurse after falling off a swing. nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? A) Telangiectasias B) Ecchymoses C) Purpura D) Urticaria

Ans: B Feedback: Telangiectasias consists of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticariais wheals or hives.

A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that thisA) Weak positive B)Moderately positive C)Strong positive D)Severely positive

Ans: B Feedback: The development of redness, fine elevations, or itching is considered a weak positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction.

A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patient's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A) Is the rash worse at a particular time or season? B)Are you allergic to any foods or medication? C)Are you having any loss of sensation in that area? D)Is your rash painful?

Ans: B Feedback: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the patient's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question A)Is anyone in your family allergic to anything? B)How long have you had this abrasion? C)Do you take any over-the-counter drugs or herbal preparations? D)What do you do for a living?

Ans: C Feedback: If suspicious areas are noted, the patient is questioned about nonprescription or herbal preparations that might be in use. Ascertaining a family history of allergies would not give helpful information at this time. The patient's lesion is not described as an abrasion. The patient's occupation may or may not be relevant; it is more important to assess for herb or drug reactions.

A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?A) Skin scrapings B)Skin biopsy C)Patch testing D) Tzanck smear

Ans: C Feedback: Patch testing is performed to identify substances to which the patient has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.

A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patient's fingernail surfaces are pitted. The nurse should suspect the presence of what A) Eczema B) Systemic lupus erythematosus (SLE) C) Psoriasis D) Chronic obstructive pulmonary disease (COPD)

Ans: C Feedback: Pitted surface of the nails is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD.

While assessing a 25-year-old female, nurse notes the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. nurse should suspect what type of health problem?A) A metabolic disorder B)A malignancy C)A hormonal imbalance D)An infectious process

Ans: C Feedback: Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen. This is often a normal genetic variation, but if it appears along with irregular menses and weight changes, it may indicate a hormonal imbalance. This combination of irregular menses and hair distribution is inconsistent with metabolic disorders, malignancy, or infection.

When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?A) The scalp B) The elbows C) The palms of the hands D) The knees

Ans: C Feedback: The epidermis is the thickest over the palms of the hands and the soles of the feet.

A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves?A) Palpation of the patient's scalp B)Palpation of the patient's upper extremities C)Palpation of a rash on the patient's trunk D)Palpation of a lesion on the patient's upper back E)Palpation of the patient's fingers

Ans: C, D Feedback: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a patient's scalp, extremities, or fingers unless contact with body fluids is reasonably foreseeable.

33. A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patient's health history, the nurse should identify what comorbidity as increasing the patient's vulnerability to skin infections? A Chronic obstructive pulmonary disease B Rheumatoid arthritis C) Gout D)Diabetes

Ans: D Feedback: Patients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

A patient 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 patient's susceptibility A)Epidermis B)Merkel cells C)Dermis D)Subcutaneous tissue

Ans: D Feedback: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment? A) Increased thickness of the subcutaneous skin layer B) Increased vascular supply to superficial skin layers C) Changes in the character and quantity of bacterial skin flora D) Increased time required for wound healing

Ans: D Feedback: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? A)Producing antibodies B)Absorbing electrolytes C)Maintaining acidbase balance D)Physically repelling pathogens E)Preventing fluid loss

Ans: D, E Feedback: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acidbase balance, or electrolyte levels.

A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?A) Obtain a swab for culture. B) Assess the characteristics of the lesion. C) Obtain a swab for pH testing. D) Apply a test dose of broad-spectrum topical antibiotic.

Assess the characteristics of the lesion.

The nurse is performing a comprehensive assessment of a patient's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?A) By examining the patient under a Wood's light B) By inspecting the patient's skin in direct sunlight C) By palpating the patient's skin D) By performing percussion of major skin surfaces

By palpating the patient's skin

An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is a cherry-red color. What should the nurse suspect? A) Carbon monoxide poisoning B)Anemia C)Jaundice D)Uremia

Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa.

A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation? A) Alopecia B)Yellowish skin tone C) Patchy, bronze pigmentation D)Hirsutism

D Cushing syndrome causes excessive hair growth, especially in women. Alopecia is hair loss from the scalp and other parts of the body. Jaundice causes a yellow discoloration in light-skinned patients, but this does not accompany Cushing syndrome. Patients that have Addison's disease exhibit a bronze discoloration to their skin due to increased melanin production.

A patient's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?A) Chronic Pain B) Impaired Skin Integrity C) Impaired Tissue Integrity D) Disturbed Body Image

Disturbed Body Image

A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?A) Decreased resistance to ultraviolet radiation B)Increased vulnerability to infection C)Diminished protection of tissues and organs D) Increased risk of skin malignancies

Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

A nurse is providing an educational presentation addressing the topic of "Protecting Your Skin." When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin?

Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin.

An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration? A)Elbows B)Lips C)Nail beds D)Sclerae

Sclerae

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? D

Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

An older adult patient is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse?A) Spend time outdoors at least twice per week B)Increase intake of leafy green vegetables C)Start taking a multivitamin each morning D)Eat red meat at least once per week

Spend time outdoors at least twice per week

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

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

The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma

A dermatologist has asked the nurse to assist with examination of a patient's skin using a Wood's light. This test will allow the physician to assess for which of the following?A) The presence of minute regions of keloid scarring B)Unusual patterns of pigmentation on the patient's skin C)Vascular lesions that are not visible to the naked eye D)The presence of parasites on the epidermis

Unusual patterns of pigmentation on the patient's skin

While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis?A) Cyanosis B) Addison's disease C) Polycythemia D) Vitiligo

Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky white spots, often symmetric bilaterally.