Chapter 60: Assessment of Integumentary Function
The nurse documents the skin color change of a dark-skinned African American patient in cardiogenic shock as: A.) Ashen gray and dull. B.) Dusky blue. C.) Reddish pink. D.) Whitish pink.
Answer: A.) Ashen gray and dull.
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced? A.) Conduction B.) Convection C.) Evaporation D.) Radiation
Answer: A.) Conduction Rationale: Three major physical processes are involved in loss of heat from the body to the environment. The first process—radiation—is the transfer of heat to another object of lower temperature situated at a distance. The second process—conduction—is the transfer of heat from the body to a cooler object in contact with it. The third process—convection, which consists of movement of warm air molecules away from the body—is the transfer of heat by conduction to the air surrounding the body.
When assessing pallor, the nurse understands that it is best observed on which of the following areas? A.) Conjunctivae B.) Nail beds C.) Bony prominences D.) Ear lobes
Answer: A.) Conjunctivae Rationale: Pallor is the absence of or a decrease in normal skin color and vascularity and is best observed in the conjunctivae or around the mouth.
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? A.) Jaundice B.) Pallor C.) Bronzed appearance D.) Cherry red face
Answer: A.) Jaundice Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin (>2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes.
The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following? A.) Keloid B.) Lichenification C.) Nodule D.) Cicatrix
Answer: A.) Keloid Rationale: The hypertrophied, elevated, irregular scar would be documented as a keloid. Lichenification refers to thickening and roughening of the skin or accentuated skin markings that may be due to repeated rubbing, irritation, or scratching. A nodule refers to an elevated, palpable solid mass that extends into the dermis. Cicatrix is another term used to denote a scar.
Which cells play a role in cutaneous immune system reactions? A.) Langerhans' cells B.) Merkel cells C.) Melanocytes D.) T-lymphocytes
Answer: A.) Langerhans' cells Rationale: Langerhans' cells are accessory cells of the afferent immune system that play a role in cutaneous (skin) immune system reactions. These cells process invading antigens and transport the antigens to the lymph system to activate the T lymphocytes. Merkel cell are receptors that transmit stimuli to the axon through a chemical synapse and therefore are associated with the sense of touch. Melanocytes are the cells that give skin its pigment.
An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? A.) Reduction in sebum production B.) Reduction in the elasticity of the skin C.) Reduction in melanin production D.) Reduction in estrogen production
Answer: A.) Reduction in sebum production Rationale: The sebum is a lubricant that prevents the drying and the cracking of the skin and hair. Due to aging, the skin becomes dry and flaked as sebum production is reduced. Loss of elasticity of the skin causes wrinkles among older adults. Reduction in melanin results in gray hair. Facial hair and sometimes chest hair appear in postmenopausal women as a result of the decreased production of estrogen.
Sudoriferous glands secrete which type of substance? A.) Sweat B.) Oil C.) Hormones D.) Cerumen
Answer: A.) Sweat Rationale: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present? A.) The skin is ashen gray and dull. B.) The skin is dusky blue. C.) The skin is reddish pink. D.) The skin is whitish pink.
Answer: A.) The skin is ashen gray and dull. Rationale: Shock due to decreased perfusion and vasoconstriction is indicated in dark skin as an ashen gray, dull appearance.
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? A.) Vesicles B.) Bullae C.) Cysts D.) Pustules
Answer: A.) Vesicles Rationale: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions.
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? A.) Vitiligo B.) Hirsutism C.) Lichenification D.) Telangiectases
Answer: A.) Vitiligo Rationale: Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? A.) Splinter hemorrhage B.) Beau's line C.) Paronychia D.) Clubbing
Answer: B.) Beau's line Rationale: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.
Which term describes the transfer of heat from the body to a cooler object in contact with it? A.) Radiation B.) Conduction C.) Lichenification D.) Evaporation
Answer: B.) Conduction Rationale: Conduction is one of the three major physical processes are involved in loss of heat from the body to the environment. Radiation is the transfer of heat to another object of lower temperature situated at a distance. Lichenification is the leather thickening of the skin. Convection consists of movement of warm air molecules away from the body.
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? A.) Epidermis B.) Dermis C.) Papillary layer D.) Stratum corneum
Answer: B.) Dermis Rationale: The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lies directly beneath the epidermis.
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? A.) Fungal infection B.) Herpes zoster C.) Psoriasis D.) Seborrheic dermatosis
Answer: B.) Herpes zoster Rationale: 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. The secretions from a suspected lesion are applied to a glass slide, stained, and examined.
A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? A.) Anemia B.) Hypoxia C.) Local trauma D.) Psoriasis
Answer: B.) Hypoxia
Which factor causes wrinkles among older adults? A.) Decrease in melanin B.) Loss of subcutaneous tissue C.) Decrease in estrogen production D.) Decrease in sebum
Answer: B.) Loss of subcutaneous tissue Rationale: The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? A.) Apply a special dye to the area. B.) Make sure that the room is darkened. C.) Protect the patient from the light. D.) Obtain samples of the lesion by scraping.
Answer: B.) Make sure that the room is darkened. Rationale: When performing a Wood's light examination, the nurse would need to ensure that the room is darkened to allow visualization of the fluorescent light so that he or she can differentiate epidermal from dermal lesions. Dye is used for immunofluorescence. There is no need to protect the patient from the light. Skin scrapings involve obtaining samples of the lesion.
The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? A.) Vitiligo B.) Psoriasis C.) Melanoma D.) Petechia
Answer: B.) Psoriasis Rationale: Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.
A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: A.) Palpable, solid tumors >3 cm. B.) Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. C.) Flat, mole-like lesions. D.) Flat macules with irregular borders.
Answer: B.) Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Rationale: Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.
A nurse is teaching a client about vitamins. What vitamin would the nurse recommend the client attain by exposing the skin to ultraviolet light on a daily basis? A.) Retinol B.) Ascorbic acid C.) Cholecalciferol D.) Tocopherol
Answer: C.) Cholecalciferol Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing cholecalciferol, or vitamin D. This vitamin is essential for preventing osteoporosis and rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus. Retinol, vitamin A, supports vision and the immune system. Ascorbic acid, vitamin C, supports the immune system and wound healing. Tocopherol, vitamin E, supports the immune system.
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? A.) Ecchymoses B.) Cherry angiomas C.) Petechiae D.) Telangiectasias
Answer: C.) Petechiae Rationale: Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? A.) Macule B.) Vesicle C.) Pustule D.) Cyst
Answer: C.) Pustule Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
Nursing students are reviewing information about primary and secondary lesions. The students demonstrate understanding of the information when they identify which of the following as a primary lesion? A.) Ulcer B.) Fissure C.) Wheal D.) Keloid
Answer: C.) Wheal Rationale: A wheal is a primary lesion. An ulcer, a fissure, and a keloid are classified as secondary lesions.
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of A.) albinism. B.) vitiligo. C.) anemia. D.) local arterial insufficiency.
Answer: C.) anemia. Rationale: In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky-white spots. Local arterial insufficiency is characterized by marked localized pallor.
Three female students share an apartment. They notice after several months that their menstrual cycles are coordinating. What is speculated to be responsible for the synchronization of their monthly cycles? A.) eccrine secretions B.) sebaceous secretions C.) apocrine secretions D.) pheromone secretions
Answer: C.) apocrine secretions Rationale: The function of apocrine secretions in humans is unknown, although the onset of secretions coincides with puberty. Some speculate that synchronization of menstruation among women in close living conditions such as a dormitory room is the result of apocrine secretions (Bhutta, 2007).
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? A.) "Have you been ingesting large quantities of alcohol?" B.) "Have you been diagnosed with Addison's disease?" C.) "Have you been in the sun a lot?" D.) "Have you been eating a large amount of carotene-rich foods?"
Answer: D.) "Have you been eating a large amount of carotene-rich foods?" Rationale: The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.
The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? A.) Flat with skin color change B.) Circumscribed border C.) Greater than 1 cm in diameter D.) Elevated and palpable
Answer: D.) Elevated and palpable Rationale: The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, nonpalpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.
Which of the following pigments influences hair color? A.) Pheromones B.) Keratin C.) Sebum D.) Melanin
Answer: D.) Melanin
Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? A.) Erosion B.) Pustule C.) Cyst D.) Spider angioma
Answer: D.) Spider angioma Rationale: A spider angioma is a vascular lesion. Erosion is a secondary lesion. Pustules and cysts are classified as primary skin lesions.
Which term refers to yellowish waxy deposits on the upper and lower eyelids? A.) Dyschromia B.) Xerosis C.) Neurodermatitis D.) Xanthelasma
Answer: D.) Xanthelasma
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? A.) Liver spots B.) Dark discoloration of the skin C.) Bright red moles D.) Yellowish waxy deposits on the eyelids
Answer: D.) Yellowish waxy deposits on the eyelids Rationale: Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia. Solar lentigo refers to liver spots. Melasma refers to dark discoloration of the skin. Cherry angioma is the term used to describe a bright red mole.
The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as A.) scale. B.) erosion. C.) ulcer. D.) fissure.
Answer: D.) fissure. Rationale: Linear cracks in the skin are documented as fissures. Scales are flakes secondary to desquamated, dead epithelium. Erosions are defined as loss of superficial epidermis that does not extend into the dermis. Ulcers show skin loss that extends past the epidermis.
A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. - Fingernails - Hair - Skin - Endocrine glands - Subcutaneous tissue
Answer: - Fingernails - Hair - Skin Rationale: Nails are layers of hard keratin that have a protective function. The epidermis contains an outer layer of dead skin that forms a tough protective protein called keratin. Hundreds of strands of keratin link together with amino acids to form hair. Endocrine glands and subcutaneous tissue are not made of keratin.
