Chapter 22 Test Bank
c. incisional remove the entire mole and tissue borders
A pt 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 pt for which type of biopsy? a. shave b. punch c. incisional d. excisional
c. check the lips and oral mucous membranes
A pt w/dark skin has been admitted to the hospital w/acute decompensated heart failure. How would the nurse assess this pt 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 the capillary refill time of the nail beds
b. thickening of the skin Lichenification is likely to occur in areas where pt scratches often.
A pt 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. symmetric they're grouped in a bilateral distribution
During assessment of the pt'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
c. talk w/the pt alone
The home health nurse notices irregular patterns of bruising at different stages of healing on an older pt's body. Which action should the nurse take first? a. ensure the pt wears shoes w/nonslip soles b. discourage the use of throw rugs throughout the house c. talk w/the pt alone and ask about bruising d. suggest the HCP prescribe radiographs
b. press on the lesion If lesion has nonvascular cause, discoloration will remain when direct pressure is applied.
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged pt's ankle. How should he nurse determine if he lesion is related to intradermal bleeding? a. elevate the pt's leg b. press firmly on the lesion c. check the temp of thee skin around the lesion d. palpate the dorsalis pedis and posterior tibial pulses
d, e Pt is at risk for lesions caused by sun exposure
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 pt 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. ask about fam hx of diabetes Presence of acanthosis nigricans in skinfolds = type 2 diabetes or risk for it
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged pt who has a BMI of 40 kg/m2. What's the nurse's appropriate action? a. discuss the use of drying agents to minimize infection risk b. instruct the pt about the use of mild soap to clean skinfolds c. teach the pt about treating fungal infections in the skinfolds d. ask the pt about a personal or family hx of type 2 diabetes
c. cotton tipped applicators
The nurse prepares to obtain a culture from a pt 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. consult with the HCP re: further testing Could be systemic prob such as malnutrition or hypothyroid.
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 pt 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 HCP about the need for further diagnostic testing d. teach the pt about using moisturizing creams and lotions to decrease dry skin
b. assess for evidence of liver disease
When performing a skin assessment, the nurse notes angiomas on the chest of an older pt. Which action should the nurse take next? a. suggest an appt w/a dermatologist b. assess the pt for evidence of liver disease c. teach the pt about skin changes w/aging d. discuss the use of sunscreen to prevent skin cancers
c. petechiae on chest & abd Petechiae are assoc w/disorders such as meningitis and coagulopathies
Which abnormality on the skin of an older pt is the priority for the nurse to discuss with the HCP? 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
ac
Which activities can the nurse working in an outpatient clinic delegate to a LPN/VN? (select all that apply) a. administer patch testing to a pt w/allergic dermatitis b. interview a new pt about chronic health probs and allergies c. apply a sterile dressing after a hcp excises a mole d. explain potassium hydroxide testing to a pt w/a skin infection e. teach a pt about site care after a punch biopsy of an upper arm lesion
b. hx of allergic rashes Pt will be put on antibiotics - would need to confirm no allergies to antibiotics
Which integumentary assessment data from an older pt admitted w/bacterial pneumonia should be of concern to the nurse? a. brown macules on extremities b. reports a hx of allergic rashes c. skin wrinkled w/tenting on both hands d. longitudinal nail ridges and sparse scalp hair
