integumentary
When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. 1 Excoriation 2 Fissure 3 Dry skin 4 Wrinkling 5 Decreased turgor
3 4 5
A nurse is obtaining a specimen of the epidermis for a skin test. What is the maximum thickness of skin that should be scraped off? Record your answer to the first decimal point. Record your answer using one decimal place. Use a leading zero if applicable.____ mm
0.1 mm The epidermis is the outermost layer of the skin. The thickness of the epidermis is 0.05 to 0.1 mm. Therefore the nurse should scrape a very thin layer of the skin for the test, the thickness of which should not exceed 0.1 mm. Text Reference - p. 414
A nurse is obtaining a sample for an indirect immunofluorescence test for a patient suspected of having systemic lupus erythematosus (SLE). Which type of sample does the nurse expect to collect? 1 Blood 2 Throat swab 3 Punch biopsy specimen of the skin 4 Shave biopsy specimen of the skin
1
A nurse is reviewing a plan of care for a female patient with acne vulgaris. The plan includes a prescription for isotretinoin. The nurse is aware that before the patient begins taking the medication, what must be determined? 1 Whether the patient is pregnant 2 Whether the patient is over 50 years of age 3 Whether the patient is suffering from any systemic illness 4 Whether the patient's work involves prolonged exposure to the sun
1
A patient has been administered a patch test to determine the patient's allergy to rubber. What is an important nursing intervention for this patient? 1 Instruct the patient to return in 48 to 72 hours for removal of allergens. 2 Keep the patient in the health care facility for close observation. 3 Instruct the patient to come back after a week for a preliminary evaluation. 4 Teach the patient how to administer an epinephrine injection, if required.
1
A patient is scheduled for a Wood's lamp test. What is the most appropriate way for the nurse to prepare the room? 1 Keep the room dark. 2 Keep the room well lit. 3 Keep an infrared lamp in the room. 4 Soundproof the room.
1
The nurse is caring for a patient with a superficial lesion. Which biopsy is best suited for this patient? 1 Shave biopsy 2 Punch biopsy 3 Incisional biopsy 4 Excisional biopsy
1
When assessing the cognitive-perceptual pattern in relation to the skin, the nurse questions the patient regarding which of these? 1 Joint pain 2 Changes in sleep habits 3 Recent changes in wound healing 4 Self-care habits related to daily hygiene
1
When assessing the patient's integumentary system, which dermatologic manifestations may indicate systemic problems? Select all that apply. 1 Pallor 2 Jaundice 3 Cyanosis 4 Skin tags 5 Cherry angiomas
1 2 3
When performing a skin assessment on a patient, which principles should the nurse follow? Select all that apply. 1 Be systematic and proceed from head to toe. 2 Use the metric system when taking measurements. 3 Ensure the patient is wearing a comfortable dress. 4 Have a private examination room with a moderate temperature. 5 Perform a lesion-specific examination followed by a general inspection.
1 2 4
A nurse is discussing the health changes associated with aging with a group of older adults in a community clinic. One of the members of the group asks about dry skin and aging. The nurse explains that, in the elderly population, dry skin comes with aging due to what? Select all that apply. 1 Decreased production of sebum. 2 Decreased immunocompetence. 3 Decreased water content in the body. 4 Decreased subcutaneous fat tissue. 5 Decreased blood supply to the skin
1 3
Which of these techniques are appropriate when the nurse is performing a physical examination of a patient's skin? Select all that apply. 1 Assessing for skin color changes. 2 Using a flashlight in a poorly lit room. 3 Pressing on a lesion to check for blanching. 4 Checking skin temperature by palpating with the palm of the hand. 5 Performing a lesion-specific examination first and then a general inspection.
1 3
The nurse is teaching a patient about the skin's ability to synthesize vitamin D when exposed to sunlight. Which instructions should the nurse include? Select all that apply. 1 Vitamin D is synthesized by the action of ultraviolet (UV) light. 2 The papillary layer helps in activating the precursors to vitamin D. 3 Ultraviolet rays act on vitamin D precursors present in the epidermis. 4 The reticular layer of the dermis plays an important role in vitamin D synthesis. 5 Endogenous synthesis of vitamin D is critical for calcium and phosphorus balance.
1 3 5
Which of these techniques are appropriate when the nurse is performing a physical examination of a patient's skin? Select all that apply. 1 Assessing for skin color changes. 2 Using a flashlight in a poorly lit room. 3 Pressing on a lesion to check for blanching. 4 Checking skin temperature by palpating with the palm of the hand. 5 Performing a lesion-specific examination first and then a general inspection.
1 3 Assess the skin for changes in color; color change is a critical factor in assessment of the skin. For lesions, note the reaction to direct pressure. If a lesion blanches on direct pressure and then refills, the redness is caused by dilated blood vessels. If the discoloration remains, it is the result of subcutaneous or intradermal bleeding or a nonvascular lesion. The examination should take place in a private room with good lighting; exposure to daylight is preferred. Temperature of the patient's skin is best assessed using the back of your hand. Perform a general inspection and then a lesion-specific examination. Text Reference - p. 419
A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply. 1 Decrease in the production of melanin 2 Increase in the production of melanin 3 Increase in the number of melanocytes 4 Decrease in the number of melanocytes 5 Decreased exposure to sun in old age
1 4
A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply. 1 Decrease in the production of melanin 2 Increase in the production of melanin 3 Increase in the number of melanocytes 4 Decrease in the number of melanocytes 5 Decreased exposure to sun in old age
1 4 With aging, the number of melanocytes decreases, causing a decrease in melanin production. An increase in the number of melanocytes causes an increase in the production of melanin, which is characterized by tanning of skin and darkening of hair. Exposure to sun is not related to the greying of hair. Text Reference - p. 416
Which data would a nurse consider least important during an assessment of skin integrity? 1 Family history of pressure ulcers 2 Presence of existing pressure ulcers 3 Overall risk as indicated by a low Braden score 4 Areas at risk for the development of pressure ulcers
1 Family history of pressure ulcers Family history is not an important factor in the development of pressure ulcers and general skin integrity. A patient deemed to be at risk on the basis of a validated tool such as the Braden scale and existing areas of skin breakdown requires immediate assessment and intervention. Text Reference - p. 419
The nurse is assessing a white patient's skin color and notices cyanosis. Where on the patient's body would the nurse most likely see this cyanosis? 1 Lips 2 Legs 3 Wrists 4 Sclera
1 On light-skinned individuals, cyanosis, or grayish blue tone, initially appears in lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet. It is not as likely on the legs, wrists, or sclera. Text Reference - p. 421
During the 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, what should the incoming nurse expect to find? 1 Tiny, purple spots on the skin 2 Large ecchymotic areas on the skin 3 Hyperkeratotic papules and plaques 4 Small, raised red areas on the soles of the feet
1 Petechiae present as tiny, purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes. Text Reference - p. 416
During an assessment interview of a female patient, the nurse finds that she is taking isotretinoin to treat acne. On further assessment, the patient expresses that she plans to conceive. Which is the most important nursing action? 1 Tell the patient to stop this medication, because it would have adverse effects on the fetus. 2 Inform the patient she can continue this medication, because the acne has reduced. 3 Teach the patient to take the drug with food to minimize the side effects. 4 Inform the patient that an overdose of Accutane can have serious consequences during pregnancy and tell her to reduce the dose.
1 The drug isotretinoin is used for treating acne. The drug can cause abnormal fetal development and should not be used by women who are pregnant or are planning to become pregnant. Whereas a nurse would normally discuss the drug's side effects and effectiveness, these issues are not relevant if the patient is instructed to discontinue the medication while trying to conceive. Text Reference - p. 419
To assess the skin turgor, the most appropriate technique for the nurse to use is which of the following? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation
1 Palpation
A nurse is assessing a patient who has yellow skin and nails. Which chemical or pigment abnormality does the nurse expect the patient to have? 1 Excess melanin 2 Excess carotenes 3 Excess oxyhemoglobin 4 Excess deoxyhemoglobin
2
A nurse is teaching a group of nursing students about the perception of cold in obese people. Which statement should be included in the education? 1 Obese people have fewer cold receptors. 2 Obese people have better fat insulation. 3 Obese people have better cold tolerance. 4 Obese people have an abnormal hypothalamic functioning.
2
A nurse scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture? 1 To identify an allergen 2 To identify a fungal infection 3 To identify a viral infection 4 To identify a bacterial infection
2
A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. Which term best describes these findings? 1 Purpura 2 Petechiae 3 Hematoma 4 Ecchymosis
2
The patient has diffuse distribution of moles on the body. A biopsy of one on the patient's back will be done to assess for malignancy. The nurse knows that what is the rationale for doing a punch biopsy? 1 It is used for a superficial lesion. 2 It provides a full-thickness of skin. 3 It is used for good cosmetic results. 4 It is used because the lesion is too large to remove
2
Which medication is most likely to have an effect on the patient's integumentary system? 1 Diuretic 2 Corticosteroid 3 Benzodiazepine 4 Calcium channel blocker
2
The nurse is caring for a patient with dark skin. The nurse suspects that the patient might have jaundice. Which areas should the nurse check to confirm the physical manifestations of jaundice? Select all that apply. 1 Fingernails 2 Oral mucosa 3 Soles and palms 4 Sclera of the eye 5 Color of the ski
2 3 4
When jaundice is suspected in a patient, which areas should the nurse check for skin color? Select all that apply. 1 Tongue 2 Earlobes 3 Conjunctiva 4 Nail beds 5 Buccal mucosa
2 3 4
The nurse is assessing an older patient. When assessing the hair and nails, the nurse will recognize that age-related changes in the hair and nails include which of these? Select all that apply. 1 Thicker hair 2 Scaly scalp 3 Thinner nails 4 Longitudinal ridging on nails 5 Prolonged blood return when nails are blanched
2 4 5 Decreased oil leads to dry, coarse hair and a scaly scalp. The hair becomes thinner. Decreased peripheral blood supply leads to thick, brittle nails, Longitudinal ridging in the nails also may occur with aging. There is prolonged blood return to the nails when they are blanched because of decreased circulation. Thicker hair and thinner nails are not normal age-related changes. Text Reference - p. 417
A patient with a long history of sun exposure has been diagnosed with skin cancer. The nurse recognizes that chronic exposure to ultraviolet (UV) rays has what effects on the skin that increase the risk for skin cancer? Select all that apply. 1 It increases blood flow to the skin. 2 It decreases the skin's ability to repair cellular damage. 3 It decreases the water content of the skin. 4 It causes degeneration of elastic fibers in skin tissue. 5 It increases the rate of cell multiplication.
2 5
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 locations should the nurse inspect for cyanosis? Select all that apply. 1 Patient's sclera 2 Patient's nail beds 3 Soles of the patient's feet 4 Palms of the patient's hands 5 Conjunctiva of the patient's eyes
2 5
A nurse educator is teaching a group of nursing students about skin assessments. The nurse asks the students the reason for assessment of cyanosis, pallor, and jaundice in the nail beds, sclera, and lips. What is the most appropriate response by the students? 1 These areas are the most accessible to a nurse. 2 These areas have the least pigmentation. 3 These areas have the highest blood flow. 4 These areas are rich in sensory receptors
2 Cyanosis, pallor, and jaundice all indicate the presence of systemic diseases. The most reliable areas for assessing these signs are nail beds, lips, sclerae, and conjunctivae, because these areas contain the least amount of pigmentation. As a result, changes in color can be easily identified. The nail beds, sclera, and lips are easily accessible; however, that is not a reason for the choice of the area during color assessment. These areas may not have high blood flow or a high amount of sensory receptors. Text Reference - p. 421
A nurse is caring for a patient diagnosed with shingles. The primary health care provider prescribes acyclovir to be administered as soon as possible. The most likely reason for the medication is to prevent what? 1 To prevent pain 2 To prevent postherpetic neuralgia 3 To prevent worsening of symptoms 4 To prevent the patient from getting restless
2 Following the onset of symptoms of shingles (herpes zoster), antiviral agents such as acyclovir should be administered within 72 hours to prevent postherpetic neuralgia. Analgesics are given to relieve pain and mild sedatives to prevent restlessness. Symptomatic treatment is given to prevent worsening of symptoms. Text Reference - p. 436
A teenaged patient reports having blackheads all over the face for the past year. The nurse recognizes that, for this patient, the blackheads are due to excessive sebum production most likely caused by what? 1 Infections 2 Hormonal alterations 3 Environmental changes 4 Sebaceous gland carcinoma
2 Hormonal changes occurring during puberty stimulate the sebaceous glands to produce more sebum. This plays a major role in causing acne and the development of comedones (blackheads). Infections, environmental alterations, and sebaceous gland carcinoma may also cause comedones but are less likely in this case. Text Reference - p. 416
A nurse is dressing the wound of a patient whose fingers were injured in an accident. One of the fingernails is missing. The patient asks the nurse about when the fingernail will grow back. What is the most appropriate answer? 1 Within 3 months 2 Within 6 months 3 Within 12 months 4 Within 15 months
2 In healthy individuals, a lost fingernail usually regenerates in three to six months. Therefore the most appropriate answer given by the nurse would be within six months. Text Reference - p. 415
A mother and her child have been diagnosed with scabies after attending a camp together. An appropriate measure in treating this condition is 1 Topical application of griseofulvin 2 Applying 5% peremethrin to the body 3 Moist compresses applied frequently 4 Administration of systemic antibiotics
2 Scabies is treated with 5% permethrin topical lotion, one overnight application with a second application one week later. Scabies is not treated with griseofulvin. The patient should be taught to keep the area dry. Systemic antibiotics should only be used if secondary infections are present. Text Reference - p. 436
A patient had an infection underneath the thumbnail, and the entire nail was removed. The patient asks the nurse how long it will take the fingernail to grow back to its normal size. What should be the nurse's answer? 1 1-2 months 2 3-6 months 3 6-12 months 4 12-24 months
2 Sometimes fingernails may be removed due to ingrowth and infection. Fingernails grow at a rate of 0.7 to 0.84 mm per week. The nail growth may vary depending upon the person's age and health. A fingernail would usually fully regenerate in 3 to 6 months. Toenails may take longer to grow, approximately 12 months or more. Text Reference - p. 415
On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding? 1 Scar 2 Fissure 3 Atrophy 4 Excoriation
2 The secondary skin lesion, called a fissure, is a linear crack or break from the epidermis to the dermis and can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is an abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area in which the epidermis is missing, which exposes dermis (e.g., abrasion or scratch). Text Reference - p. 420
Inspection of an obese female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What should the nurse most suspect to be the cause of the odor? 1 Ecchymosis 2 Colonization by yeast or bacteria 3 Age-related integumentary changes 4 Atrophy of the skin under the abdominal folds
2 Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising. An unusual odor would not normally be attributed to age-related changes or skin atrophy. Text Reference - p. 421
A nurse is assessing a patient with chalky white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis? 1 Keloid 2 Vitiligo 3 Intertrigo 4 Hypopigmentation
2 Vitiligo is a skin condition characterized by complete loss of melanin in the affected area, which results in chalky white patches. This condition is usually inherited. Keloid is an overgrowth of scar tissue at the site of skin injury. Intertrigo is characterized by presence of rashes in intertriginous areas, such as the axillae and the area under the breast. It is usually due to inflammation of the overlying surface of skin. Hypopigmentation also occurs due to loss of pigmentation but is not an inherited disorder. Hypopigmentation is usually due to chemical agents, nutritional factors, burns, inflammation, or infection. Text Reference - p. 423
A nurse educator explains to a group of nursing students why skin becomes darker in color when exposed to sunlight. Which statement by a student indicates the teaching has been understood? 1 "The rays from the sun burn the outer layer of the skin, making the skin dark and painful." 2 "The rays from the sun stimulate the production of melanin, giving a tan to the skin." 3 "The rays from the sun inhibit the production of melanin, causing the skin to darken." 4 "The rays from the sun cause increased blood flow to the skin, giving a dark red color to the skin."
2 "The rays from the sun stimulate the production of melanin, giving a tan to the skin."
While conducting a skin assessment, the nurse observes that the patient's skin does not return to its normal position after pinching. What is the appropriate nursing intervention in this situation? 1 Administer prescribed antibiotics to the patient. 2 Administer water and electrolytes to the patient. 3 Check the patient for abnormal levels of hemoglobin. 4 Check the patient for abnormal levels of hormones
2 Administer water and electrolytes to the patient.
Which disease condition can be found more in fair-skinned patients than in patients with more pigmentation in their skin? 1 Keloids 2 Melanoma 3 Nevus of ota 4 Traction alopecia
2 Melanoma
A patient is having a diagnostic test performed to check a skin rash for a possible fungal infection. The nurse will prepare for which test? 1 A patch test 2 A shave biopsy 3 A potassium hydroxide (KOH) microscopic test 4 The Tzanck test (Wright's and Giemsa's stain
3
During an initial assessment of an obese female patient, what specific question should the nurse ask to determine the metabolic pattern related to her skin? 1 Is your sleep being disturbed by any skin condition? 2 Is there any specific food that also causes a skin allergy? 3 Do you have any chafing or a rash in areas where skin overlaps? 4 Are there any skin changes during exercise or other activities?
3
When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. 1 Excoriation 2 Fissure 3 Dry skin 4 Wrinkling 5 Decreased turgor
3 4 5 Older adults do not have the same skin as younger adults, and there are many skin changes associated with aging that are normal. These include dry skin, wrinkling, and a decrease in turgor. Older adults may have decreased extracellular water, surface lipids, and sebaceous gland activity, leading to dry skin. Decreased subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening may lead to wrinkling and decreased turgor. Excoriation and fissures are abnormal findings on the skin and need further evaluation. Text Reference - p. 416
A patient is having a diagnostic test performed to check a skin rash for a possible fungal infection. The nurse will prepare for which test? 1 A patch test 2 A shave biopsy 3 A potassium hydroxide (KOH) microscopic test 4 The Tzanck test (Wright's and Giemsa's stain)
3 A KOH test is done to examine hair, scales, or nails for superficial fungal infection. A patch test is done to check for allergic reactions. A shave biopsy is done to provide a thin specimen for diagnostic purposes. The Tzanck test is done to assess for the presence of the herpes virus. Text Reference - p. 425
What condition does the nurse suspect in an asthmatic patient who reports erythema, oozing vesicles, and severe itching of the skin? 1 Urticaria 2 Drug reaction 3 Atopic dermatitis 4 Allergic contact dermatitis
3 Asthma and atopic dermatitis are atopic diseases with the same pathogenic base with regard to allergic reaction and type of oversensitivity leading to allergic inflammation. Therefore, atopic dermatitis may be associated with asthma. Urticaria is an allergic reaction associated with erythema and edema in the upper epidermis. A drug reaction is caused by any drug that acts as an antigen and causes a hypersensitivity reaction. Allergic contact dermatitis is a manifestation of delayed hypersensitivity reaction, which results from sensitization after one or more exposures. It is characterized by the appearance of lesions two to seven days after contact with an allergen. Text Reference - p. 438
Which laboratory test would be most important to check in the patient presenting with purpura? 1 Urinalysis 2 Serum electrolytes 3 Coagulation studies 4 White blood cell coun
3 Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore, it is most important for the nurse to assess the patient's coagulation studies. Electrolytes, urinalysis, and white blood cells would not reveal a reason for why purpura are present. Text Reference - p. 421
A 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? 1 Warm, flushed skin, alopecia, and thin nails 2 General hyperpigmentation and loss of body hair 3 Pale skin, pale mucous membranes, hair loss, and nail dystrophy 4 Cold, dry, pale skin, dry, coarse hair, and brittle, slow growing nails
4
The nurse is reviewing the function of the skin layers. Which of these is the primary function of the epidermis layer of the skin? 1 Insulation 2 Excretion 3 Protection 4 Absorption
3 The epidermis, the thin avascular superficial layer of the skin, is made up of an outer dead cornified portion that serves as a protective barrier and a deeper, living portion that folds into the dermis. The subcutaneous layer of the skin provides insulation. The primary function of the skin is not to insulate, to excrete sweat, or to absorb. Text Reference - p. 414
When assessing a 73-year-old female patient, the nurse found wrinkles, sagging breasts, and tenting of the skin, gray hair, and thick brittle toenails. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system? 1 Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails 2 Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation 3 Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply 4 Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation
3 The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching. Text Reference - p. 416
A nurse is giving a lecture on nutrition to a group of nursing interns. The nurse says that sunlight is the best source of vitamin D. Based on their previous knowledge, what would be the most appropriate interpretation of this statement by the interns? 1 Sunlight contains vitamin D, which is easily absorbed by the skin. 2 Exposure to sunlight increases craving for foods rich in vitamin D. 3 Sunlight stimulates the production of vitamin D in the body. 4 Sunlight causes proliferation of the cells containing vitamin D precursors.
3 The ultraviolet (UV) rays present in sunlight act on the vitamin D precursors present in epidermal cells and form Vitamin D. Sunlight does not contain vitamin D. Exposure to sunlight does not increase craving for foods rich in Vitamin D. The UV rays do not help in proliferation of Vitamin D precursors but simply convert them to vitamin D. Text Reference - p. 416
The nurse assesses circumscribed, hypertrophic, flesh-colored papules on a patient's knee. The patient states they are recurring even after removal. How should the nurse document these findings? 1 Plantar warts 2 Herpes zoster 3 Verruca vulgaris 4 Herpes simplex virus type 1
3 Verruca vulgaris is characterized by circumscribed, hypertrophic, flesh-colored papules that are limited to the epidermis. Plantar warts are found on the bottom surface of the foot; they may grow inward as a result of the pressure of walking and standing. Herpes zoster is characterized by linear distribution along a dermatome of grouped vesicles and pustules on an erythematous base. Herpes simplex virus type 1's clinical manifestations are single or grouped vesicles on an erythematous base occurring with systematic symptoms of fever and malaise. Text Reference - p. 436
A nurse asks a nursing student to determine the skin color of a patient whose skin is tanned in the exposed areas. Where is the best place on a patient's body to accurately determine skin color? 1 Face 2 Palms 3 Nail beds 4 Buttocks
4
When assessing a dark-skinned patient, the nurse finds that there are dark longitudinal bands in the patient's nail beds. What is the most likely interpretation of this finding? 1 The patient may have a thyroid disorder. 2 Anemia may be present in this patient. 3 It is a normal finding in this patient. 4 The patient may have psoriasis.
3 It is a normal finding in this patient.
To obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use? 1 Inspection of skin color 2 Examination for vascularity 3 Palpation of skin with the hand 4 Percussion of the skin on the back
3 Palpation of skin with the hand Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin. Text Reference - p. 419
A nurse is caring for a patient who has taken a potassium hydroxide (KOH) skin test. The results of the test are positive. What would be the interpretation of this test? 1 The patient has a skin allergy. 2 The patient has a malignant skin condition. 3 The patient has a fungal infection of the skin. 4 The patient has systemic lupus erythematosus (SLE)
3 The patient has a fungal infection of the skin.
A nurse is assessing a patient with psoriasis. The nurse explains the pathology of psoriasis, stating that it occurs due to abnormal changes in the cell cycle of the skin layers. Which change in the cell cycle is the nurse referring to? 1 The outer dead layer of skin cells is not shed. 2 The inner layer of skin stops producing new skin cells. 3 The rate of removal of outer dead skin is much more than the rate of production of new skin cells. 4 The rate of new skin cell production is much more than the rate of removal of outer dead skin cells
4
On inspection of a patient's skin, the nurse notes dilated, superficial, cutaneous small blood vessels on the patient's face. This assessment finding is called 1 Vitiligo 2 Petechiae 3 Intertrigo 4 Telangiectasia
4
The nurse assessed the patient's skin lesions as circumscribed, with a superficial collection of serous fluid, and less than 0.5 cm in diameter. These lesions would be called: 1 Wheals 2 Papules 3 Pustules 4 Vesicles
4
The nurse is assessing a patient who has dark skin for cyanosis. What assessment findings would indicate cyanosis in individuals with dark skin? 1 Reddish skin tone 2 Deeper brown or purple skin tone 3 Grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, palms, and soles 4 Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds
4
The nurse is caring for a patient who has yellow discoloration of the skin. The nurse also observes that the patient's sclerae are not yellow in color. What is the best nursing action in this situation? 1 Advise the patient to undergo a diagnostic test for jaundice. 2 Advise the patient to decrease the intake of food rich in Vitamin B12. 3 Advise the patient to undergo an immunofluorescent microscopic test. 4 Advise the patient to decrease consumption of vegetables rich in carotene
4 Carotenemia is a condition that occurs due to excessive consumption of vegetables rich in carotene. It is characterized by yellow discoloration of the skin, mostly noticeable on the palms and soles, but not in the sclerae. Jaundice also causes yellow discoloration of skin but is best observed in the sclerae. There is no need for the patient to undergo a diagnostic test for jaundice, because the patient shows no yellow discoloration of the sclerae. Vitamin B12 is a water-soluble vitamin responsible for the functioning of the brain and nervous system. Decreasing intake of Vitamin B12 will not reduce the symptoms of carotenemia. An immunofluorescent test is used to identify the specific, abnormal antibody proteins that cause certain skin diseases. Carotenemia is caused due to an increase in carotene levels, not due to the production of abnormal antibodies. Therefore, an immunofluorescent test is not required for this patient. Text Reference - p. 422
The patient has been snacking on carrots each day and has developed carotenemia. The nurse knows that improvement in this condition will be most evident on which part of the patient's body? 1 Face 2 Chest 3 Sclera 4 Palms of hands
4 Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet. It is not noticeable on the face, chest, or sclera. Text Reference - p. 423
While performing a capillary refill test, the nurse observes that a patient's nail beds become blanched and remain discolored even when the pressure on the nail beds is released. What can the nurse interpret from this finding? 1 The findings are normal. 2 Jaundice may be present. 3 The patient may have a thyroid disorder. 4 The patient may have subcutaneous bleeding
4 If blanching of the nail persists in spite of removing pressure from the nail bed, it may indicate subcutaneous bleeding. It is not a normal finding because the nail bed should turn back to pink once the pressure is removed. In jaundice, the nail bed is yellow in color. In thyroid disorders, the nail becomes uneven and thick. Text Reference - p. 421
A patient who is obese and has a diagnosis of diabetes is at risk for a bacterial skin infection. For what infection should the nurse educate the patient to monitor? 1 Cellulitis 2 Impetigo 3 Carbuncle 4 Furunculosis
4 Patients who are obese and diabetic are at increased risk for furunculosis because of the likelihood of skin folds containing excess moisture. Therefore, the nurse should warn the patient about the possibility of furunculosis. Cellulitis may be a secondary complication or a primary infection; it most often results from a break on the skin's surface. Impetigo is most common in patients with poor hygiene. Many factors are responsible for the development of carbuncle. Text Reference - p. 434
To determine the presence of petechiae in a patient with dark skin, the nurse should assess what part of the body? 1 Nail 2 Face 3 Buttocks 4 Conjunctiva
4 Petechiae are small pinpoint lesions. The nurse should check for these lesions in the conjunctiva of the eye or buccal mucosa in dark-skinned people. Unlike fair-skinned people, these lesions are difficult to see on the nail, face, or buttocks of dark-skinned people. Text Reference - p. 421
A 14-year-old girl and her mother come to see the nurse practitioner for treatment of the daughter's acne. For what should the nurse assess the patient to show the existence of acne? 1 Ulcers 2 Wheals 3 Vesicles 4 Pustules
4 Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne. Text Reference - p. 420
A nurse is assessing a male client who reports small papules and pustules in the beard area. The papules started appearing after he shaved his beard the previous day. Based on this information, what is the most likely patient diagnosis? Acne 2 Moles 3 Comedo 4 Pseudofolliculiti
4 Pseudofolliculiti Pseudofolliculitis is an inflammatory reaction that occurs in the beard area after shaving too closely. This inflammation is a response to the in-growth of hair after shaving and is manifested as pustules or papules. Acne is also characterized by papules and pustules but is unlikely to occur in the beard area after shaving. Acne is usually due to an infection or hormonal changes. Moles are small dark lesions caused by benign overgrowth of melanocytes. Comedos (blackheads and whiteheads) are enlarged hair follicles that are plugged with sebum, bacteria, and skin cells. They may occur due to heredity, drugs, or hormonal changes. Text Reference - p. 423
The nurse is assessing the integumentary manifestations of four geriatric patients. Which patient does the nurse suspect to have decreased immunocompetence?
Decreased immunocompetence in geriatric patients leads to an increase in neoplasms. Therefore, patient 2 has decreased immunocompetence. Dry, flaking skin with possible signs of excoriation caused by scratching is caused due to decreased extracellular water, surface lipids, and sebaceous gland activity in elderly patients. Therefore, patient 1's manifestations do not indicate decreased immunocompetence. In elderly patients, solar lentigines on the face and backs of the hands are caused by increased focal melanocytes in the basal layer with pigment accumulation. Therefore, patient 3 has hyperpigmentation, not compromised immunocompetence. A decreased rate of wound healing indicates that patient 4 has decreased proliferative capacity, not decreased immunocompetence. Text Reference - p. 417
The nurse is caring for four patients. Which patient does the nurse suspect will have delayed wound healing?
Diabetes mellitus is a condition characterized by high blood sugar levels. High blood glucose levels impair tissue interiority and delay wound healing. Anemia causes pallor, or pale color of the skin, not delayed wound healing. It results from reduced amounts of oxyhemoglobin. Liver diseases, jaundice for example, cause yellow coloration of the skin, not delayed wound healing. Respiratory disorders cause cyanosis, not delayed wound healing. Text Reference - p. 417
The nurse is assessing the integumentary system of four female geriatric patients. In which patient does the nurse expect to find a cumulative androgen effect?
Geriatric female patients with cumulative androgen effect or decreased estrogen levels will have facial hirsutism and baldness. Therefore, the nurse expects to find a cumulative androgen effect with patient 2. Gray or white hair indicates that patient 1 has low levels of melanin and melanocytes. A scaly scalp with dry, coarse hair indicates that patient 3 has decreased production of oil. Thinning or loss of hair in the outer half or outer third of eyebrows and backs of the legs is not caused by low estrogen levels. Therefore, patient 4 does not show a cumulative androgen effect. Text Reference - p. 417
The nurse is assessing four adolescent female patients. Which patient does the nurse suspect to have low estrogen levels?
Male distribution of hair in women is called hirsutism. It occurs due to a decrease in estrogen levels or abnormality in the adrenal glands or ovaries. Therefore, the nurse suspects that patient 2 has low estrogen levels. A cyst is a sac containing fluid or semisolid material. It is formed by the obstruction of a duct or a gland, or because of a parasitic infection. The presence of blackheads or whiteheads, enlarged hair follicles plugged with sebum, bacteria, and skin cells, is called comedo. It is caused by hormonal changes during puberty or pregnancy. Therefore, the nurse suspects that patient 3 has high estrogen levels. Loss of pigmentation resulting in lighter patches of skin may be caused by a decrease in melanin levels, not low estrogen levels. Text Reference - p. 422
While explaining the structure of the skin to a patient, the nurse says that the outermost layer of the skin consists mainly of dead cells. The patient asks the nurse, "Why do our bodies need these dead cells?" What is the most appropriate answer for the nurse to give? 1 To provide nutrition to the viable cells underneath 2 To protect the viable cells underneath 3 To preserve water for the viable cells underneath 4 To provide antiseptic properties that prevent infection in the body
To protect the viable cells underneath