Lewis Med-Surg Ch 23

A 38-year-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 birth control used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face

ANS: B 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 birth control has the most potential for serious adverse medication effects

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.

ANS: B 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

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will 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

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification 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 as a result of scratching the skin

Age related changes in the skin include (select all that apply): A. oily scalp B. a loss of collagen C. thicker, brittle nails D. thinner, fragile nails E. improved blood supply

B, C

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar

a

Which nursing intervention can help a client maintain healthy skin? a. Keep the client well hydrated. b. Avoid bathing the client with mild soap. c. Remove adhesive tape quickly from the skin. d. Recommend wearing tight-fitting clothes in hot weather.

a

What is the most common diagnostic test used to determine a causative agent of skin infections? a. Culture b. Tzanck test c. Immunofluorescent studies d. Potassium hydroxide (KOH) slides

a. A culture can be performed to distinguish among fungal, bacterial, and viral infections. A Tzanck test is specific for herpesvirus infections, potassium hydroxide slides are specific for fungal infections, and immunofluorescent studies are specific for infections that cause abnormal antibody proteins.

Inspection of an obese, female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. The nurse would suspect that the odor is most likely caused by A. Ecchymosis. B. Colonization by yeast or bacteria. C. Age-related integumentary changes. D. Atrophy of the skin under the abdominal folds.

b

The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing? a. Inflammatory b. Migratory c. Proliferation d. Maturation

b

Which of the following medications are the most likely to have an effect on the patient's integumentary system? A. Diuretic B. Corticosteroid C. Benzodiazepine D. Calcium channel blocker

b

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which of the following locations should the nurse inspect for cyanosis (select all that apply)? A. Patient's sclera B. Patient's nail beds C. Soles of the patient's feet D. Palms of the patient's hands E. Conjunctiva of the patient's eyes

b, e

A patient has a plaque lesion on the dorsal forearm. Which type of biopsy is most likely to be used for diagnosis of the lesion? a. Punch biopsy b. Shave biopsy c. Incisional biopsy d. Excisional biopsy

b. A shave biopsy is done for superficial lesions that can be scraped with a razor blade, removing the full thickness of the stratum corneum. An excisional biopsy is done when the entire removal of a lesion is desired. Punch biopsies are done with larger nodules to examine for pathology, as are incisional biopsies.

The nurse observes that redness remains after palpation of a discolored lesion on the patient's leg. This finding is characteristic of a. varicosities. b. intradermal bleeding. c. dilated blood vessels. d. erythematous lesions.

b. Discolored lesions that are caused by intradermal or subcutaneous bleeding do not blanch with pressure, whereas those caused by inflammation and dilated blood vessels will blanch and refill after palpation. Varicosities are engorged, dilated veins that may empty with pressure applied along the vein.

Which of the following laboratory tests would be most important to check in a patient presenting with purpura? A. Urinalysis B. Serum electrolytes C. Coagulation studies D. White blood cell count

c

When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? a. Increased bruising b. Excess perspiration c. Decreased extracellular fluid d. Decreased peripheral blood supply

c. In older adults the dermis loses volume and has fewer blood vessels, which contributes to decreased extracellular water. Some older people do not drink enough fluids and this can also contribute to dry skin. In older adults there are also decreased surface lipids and apocrine and sebaceous gland activity. Increased bruising from capillary fragility does not contribute to dry skin.

A 14-year-old female and her mother have presented to their nurse practitioner seeking treatment for the daughter's acne. The nurse would recognize that acne is characterized by the presence of multiple A. Ulcers. B. Wheals. C. Vesicles. D. Pustules.

d

Which of these statements by the client with pruritus requires the need for reteaching? a. "I will avoid using fabric softeners because harsh chemicals may irritate" b. "I will shower after I get out of the pool" c. "I will take only cool or lukewarm baths" d. "I will wear wool gloves to prevent scratching my skin"

d, Wool is itchy!

Your significant other has developed scaly, crusty areas on their lower leg. They tell you that "the itching is driving me batty!" Since you are so smart, you suspect which of the following: 1. eczema 2. psoriasis 3. impetigo 4. shingles

1

You are helping in an elementary school and the parents want to know what you are looking for when you are looking for parasitic skin infections. You would tell them (select all that apply) 1. scabies 2. carbuncles 3. lice 4. keloids 5. bed bugs

1, 3, 5

Giving discharge instructions to a burn patient, the topical agent she is to apply to her wound will cause permanent staining of clothes, linen, walls and floors. Which of the following will she be using: 1. mafenide acetate ( Sulfamylon) 2. silver sulfadiazine (Silvadene) 3. bacitracin ointment 4. silver nitrate 5. O-wutagufiam

2

You are assessing a baby and notice small, pimplelike protrusions on her cheeks. These protrusions are called: 1. pustules 2. papules 3. vesicles 4. macules

2

a recent recipient of a xenograft asked what the heck it was, so you told him: 1. we took a piece of your skin from somewhere else and put it where you needed it 2. we took a piece of skin from your twin and placed it where you needed it 3. we took a piece of skin from an animal and placed it where you needed it 4. we took a piece of skin from another person and placed it where you needed it

3, xenograft (1 is an autograft, 2 is an isograft, 4 is a homograft)

The friend of a friend asks you if they should take antibiotics to help get rid of their shingles. You tell them: 1. what do I look like, a doctor? 2. a hammer would probably work better 3. yes they would work fine as shingles are a bacterial infection 4. no because shingles are a virus

4

Individuals with dark skin are more likely to develop: A. keloids B. wrinkles C. skin rashes D. skin cancer

A

The nurse assess the skin lesions as circumscribed, superficial, elevated, solid, and greater than 0.5cm in diameter. They would be: A. plaques B. papules C. pustles D. wheals

A

To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is: A. palpation B. inspection C. percussion D. auscultation

A

When assessing the activity-exercise pattern in relation to the skin, the nurse questions the patient regarding: A. protection against sun exposure B. the use of moisturizing shampoo C. self-care habits related to daily hygiene D. the presence of dark circles under the eyes

A

When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Teach the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist.

ANS: A 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 initial action should be further assessment

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse? a. Reports a history of allergic rashes b. Scattered macular brown areas on extremities c. Skin brown and wrinkled, skin tenting on forearm d. Longitudinal nail bed ridges noted; sparse scalp hair

ANS: A 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

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (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. Teach a patient about site care after a punch biopsy of an upper arm lesion. e. Explain potassium hydroxide testing to a patient with a superficial skin infection.

ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require more critical thinking and registered nurse (RN) level education and scope of practice

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

ANS: C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant. 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

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best 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.

ANS: C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult 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

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. Local anesthetic, syringe, and intradermal needle

ANS: C 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 is not needed because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Discourage the use of throw rugs throughout the house. b. Ensure the patient has a pair of shoes with non-slip soles. c. Talk with the patient alone and ask about what caused the bruising. d. Notify the health care provider so that x-rays can be ordered as soon as possible.

ANS: C 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. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurse's first nursing action is to further assess the patient

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen

ANS: D 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

During assessment of the patient's skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? a. Confluent b. Zosteriform c. Generalized d. Symmetric

ANS: D The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions

When taking the health history of an older adult, the nurse discovers that the patient has 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

ANS: D, E 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

A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is: a. "There is no pain associated with this procedure" b. "The local anesthetic may cause a burning or stinging sensation" c. A preoperative medication will be given so you will be sleeping and will not feel any pain" d. "There is some pain, but the physician will prescribe an opioid analgesic following the procedure"

B

Diagnostic testing is recommended for skin lesions when: A. a health history cannot be determined B. a more definitive diagnosis is needed C. percussion reveals an abnormal finding D. treatment with prescribed medication has failed

B

On inspection of the patient's skin, the nurse notes hypertrophied scarring at the site of a prior injury to the skin. This assessment abnormality is called: A. vitiligo B. keloid C. telangiectasia D. lichenification

B

The primary function of the skin is: A. insulation B. protection C. sensation D. absorption

B

During the physical examination of a patient's skin, the nurse would: A. use a flashlight if the room is poorly lit B. note cool, moist skin as a normal finding C. pinch up a fold of skin to assess turgor D. perform a lesion-specific examination first and then a general inspection

C

A client has a pressure ulcer with a large amount of necrotic tissue. Which of the following physician's orders or nursing interventions might you carry out? (select all that apply) a. enzymatic debridement b. wet-to-dry or wet-to-moist dressings c. application of a closed dressing d. a therapeutic bath e. rub the skin vigorously with gauze

a, b, d

Your niece asks you about the rash she "has grossed out for about a year" on her arm. You have knowledge of chronic skin disorders and would suspect which of the following? (select all that apply) a. vitiligo b. dermatitis c. urticaria d. psoriasis

a, b, d

During change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, the incoming nurse may expect to find A. Tiny, purple spots on skin. B. Large ecchymotic areas on skin. C. Hyperkeratotic papules and plaques. D. Small, raised red areas on the soles of the feet.

a, petechiae - tiny, purple spots

A woman calls the health clinic and describes a rash that she has over the abdomen and chest. She tells the nurse it has raised, fluid-filled, small blisters that are distinct. a. Identify the type of primary skin lesion described by this patient. b. What is the distribution terminology for these lesions? c. What additional information does the nurse need to document the critical components of these lesions?

a. vesicles; b. discrete, localized to the chest and abdomen. c. color, size, and configuration

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is a. thickening of the skin. b. dermatitis in the folds of her skin. c. loss of color in diffuse areas of her skin. d. a firm plaque caused by fluid in the dermis.

b. Intertrigo is dermatitis in the folds of her skin. Thickening of the skin is lichenification. Loss of color in diffuse areas of skin is vitiligo. A firm plaque caused by fluid in the dermis is a wheal.

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo

b. Scales are excess dead epidermal cells. A pustule is a circumscribed collection of leukocytes and free fluid. Comedo is associated with acne vulgaris.

The patient asks the nurse what telangiectasia looks like. Which is the best description for the nurse to give the patient? a. A circumscribed, flat discoloration b. Small, superficial, dilated blood vessels c. Benign tumor of blood or lymph vessels d. Tiny purple spots resulting from tiny hemorrhages

b. Telangiectasia looks like small, superficial, dilated blood vessels. A small circumscribed, flat discoloration describes a macule. A benign tumor of blood or lymph vessels describes an angioma. Tiny purple spots resulting from tiny hemorrhages describes petechiae.

When obtaining important health information from a patient during assessment of the skin, it is important for the nurse to ask about a. a history of freckles as a child. b. patterns of weight gain and loss. c. communicable childhood illnesses. d. skin problems related to the use of medications.

d. A careful medication history is important because many medications cause dermatologic side effects and patients also use many over-the-counter preparations to treat skin problems. Freckles are common in childhood and are not related to skin disease. Communicable childhood illnesses are not directly related to skin problems, although varicella viruses may affect the skin in adulthood. Patterns of weight gain and loss are not significant but the presence of obesity may cause skin problems in overlapping skin areas.

What is the primary difference between an excoriation and an ulcer? a. Ulcers do not penetrate below the epidermal junction. b. Excoriations involve only thinning of the epidermis and dermis. c. Excoriations will form crusts or scabs whereas ulcers remain open. d. An excoriation heals without scarring because the dermis is not involved.

d. An excoriation is a focal loss of epidermis; it does not involve the dermis and, as such, does not scar with healing. Ulcers do penetrate into and through the dermis and scarring does occur with these deeper lesions. Epidermal and dermal thinning is atrophy of the skin but does not involve a break in skin integrity. Both excoriations and ulcers have a break in skin integrity and may develop crusts or scabs over the lesions.

Priority Decision: When performing a physical assessment of the skin, what should the nurse do first? a. Palpate the temperature of the skin with the fingertips. b. Assess the degree of turgor by pinching the skin on the forearm. c. Inspect specific lesions before performing a general examination of the skin. d. Ask the patient to undress completely so all areas of the skin can be inspected.

d. It is necessary for the patient to be completely undressed for an examination of the skin. Gowns should be provided and exposure minimized as the skin is inspected generally first, followed by a lesion-specific examination. Skin temperature is best assessed with the back of the hand and turgor is best assessed with the skin over the sternum.