Patho Ch 46 Skin Disorders

Dysplastic nevi are precursors of malignant melanoma that are: A. Larger than other nevi B. Oval epidermal nests C. Dermal cords of cells D. Brown, rounded papules

A Dysplastic nevi, a precursor of malignant melanoma, are larger than other nevi (often >5 mm in diameter), have a flat, slightly raised plaque and pebbly surface, or a target-like lesion with a darker, raised center and irregular border. Nevocellular nevi are tan to deep brown, uniformly pigmented, small papules with well-defined and rounded borders that grow in nests or clusters along the dermal-epidermal junction. Eventually, most junctional nevi grow into the surrounding dermis as nests or cords of cells.

Which of the following actions could result in pressure ulcer formation? A. Pulling a stroke client up in bed B. Turning a client from side to side every 2 hours C. Allowing a client to side up in a chair at mealtime D. Applying powder to buttocks area when diaphoresis has become a problem

A Factors contributing to the development of pressure ulcers include external pressure that compresses blood vessels and friction and shearing forces that tear and injure blood vessels. Shearing forces are caused by the sliding of one tissue layer over another with stretching and angulation of blood vessels, causing injury and thrombosis. Shear occurs when the skeleton moves, but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed. Whether a person is sitting or lying down, the weight of the body is borne by tissues covering the bony prominences. Moisture contributes to pressure ulcer formation by weakening the cell wall of individual skin cells and by changing the protective pH of the skin.

Papulosquamous dermatoses, such as psoriasis, are a group of skin disorders characterized by: A. Scaling papules B. Granular scabbing C. Raised red borders D. Nodular ulcerations

A Papulosquamous dermatoses are a group of skin disorders characterized by scaling papules and plaques. Nodular ulcerative type is a frequently occurring type of basal cell carcinoma. Squamous cell carcinoma is a red-scaling, keratotic, slightly elevated lesion that later grows outward, with large ulcerations and crusts with raised, erythematous borders. Varicella (chickenpox) is caused by the varicella-zoster virus; characteristic skin lesion occurs in three stages: macule, vesicle, and granular scab.

Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the client with psoriasis, a disorder that results from: A. Increased epidermal cell turnover B. An IgE-mediated immune reaction C. Hormonal influences on sebaceous gland activity D. Human papillomaviruses (HPV)

A Psoriasis is characterized by increased epidermal cell turnover with marked epidermal thickening, a process called hyperkeratosis. Hives are caused by an IgE-mediated immune reaction, and HPV causes warts. Dysfunction of the sebaceous glands results in acne.

Which of the following disorders of the skin is most likely to respond to treatment with systemic antibiotics? A. Acne vulgaris B. Urticaria C. Atopic dermatitis D. Verrucae

A The etiology of acne vulgaris is bacterial, and some clients may require treatment with systemic antibiotics. Urticaria (hives) and atopic dermatitis result from allergic and hypersensitivity processes. Verrucae, or warts, are of viral origin and thus unresponsive to antibiotic therapy.

A 5-year-old girl has been presented for care by her father due to her recent development of macules on her trunk, extremities, and mucous membranes. The child is mildly febrile, but her primary symptom is extreme pruritus. What disorder of the skin should the clinician who is assessing the child first suspect? A. Varicella B. Lichen planus C. Rosacea D. Impetigo.

A Varicella (chickenpox) begins with a macular stage that is characterized by the development of macules over the trunk, spreading to the limbs, buccal mucosa, scalp, axillae, upper respiratory tract, and conjunctiva. Mild to extreme pruritus accompanies the lesions, and clients are often mildly febrile. Impetigo manifests vesicles or pustules that are primarily on the face. Rosacea and lichen planus are chronic skin disorders of older persons.

Atopic dermatitis can be described as: Select all that apply. A. Vesicle formation B. Oozing C. Round, erythematous papules that enlarge and coalesce D. Raised wheals with associated itching

A, B The lesions of atopic dermatitis are usually characterized by vesicle formation, oozing, and crusting with excoriations. The lesions of erythema multiforme are round, erythematous papules that enlarge and coalesce, changing to concentric zones of color appearing as "target" or "iris" lesions. Urticaria, or hives, is a common skin disorder characterized by the development of edematous wheals accompanied by intense itching.

A teenager with rosacea should be educated that in addition to the "blush appearance" on the face, she should also assess for which of the following additional complications? Select all that apply. A. Inflamed and tender axillary lymph nodes B. Eye problems C. Edema of the eyelids D. Large abscesses on the upper arms and neck

B, C Rosacea is a chronic skin disorder of middle-aged and older persons. The blush eventually becomes a permanent, dark-red erythema on the nose and cheeks that sometimes extends to the forehead and chin. Ocular problems occur in at least 50% of persons with rosacea. Prominent symptoms include eyes that are itchy, burning, or dry; a gritty or foreign body sensation; and erythema and swelling of the eyelid. Acne conglobata occurs later in life as a severe, chronic form of acne. Comedones, papules, pustules, nodules, abscesses, cysts, and scars occur on the back, buttocks, and chest. Lesions occur to a lesser extent on the abdomen, shoulders, neck, face, upper arms, and thighs. The comedones or cysts have multiple openings, large abscesses, and interconnecting sinuses.

Which one of the following skin disorders seen in elderly persons is considered a premalignant lesion? A. Cherry angiomas B. Actinic keratosis C. Solar lentigines D. Telangiectases

B Actinic keratoses are the most common premalignant skin lesions that develop on sun-exposed areas. Solar lentigines are tan to brown, benign spots on sun-exposed areas. They are commonly referred to as liver spots. Senile angiomas (cherry angiomas) are smooth, cherry-red or purple, dome-shaped papules, usually found on the trunk. Telangiectases are single dilated blood vessels, capillaries, or terminal arteries that appear on areas exposed to sun or harsh weather, such as the cheeks and the nose.

A 79-year-old client has been confined to bed after a severe hemorrhagic stroke that has caused hemiplegia. Which of the following measures should his care team prioritize in the prevention of pressure ulcers? A. Prophylactic antibiotics B. Repositioning the client on a scheduled basis C. Applying protective dressings to vulnerable areas D. Parenteral nutrition

B Although adequate nutrition is important in both the prevention and treatment of pressure ulcers, the most important intervention is to prevent pressure and ischemia. This can be accomplished by frequently repositioning the client. Prophylactic antibiotics are not commonly used, and dressings are not normally required unless skin breakdown is evident.

A 44-year-old man has been brought to the emergency department with severe electrical burns resulting from a workplace accident. The most immediate threat to this client's survival at this time is: A. Infection B. Hemodynamic instability C. Acute pain D. Decreased protein synthesis and impaired healing

B Although infection and the potential for sepsis are highly significant risks for clients with burns, the most immediate threat is hemodynamic instability. Pain control is essential, but inadequate pain control does not pose a direct threat to survival. The healing process is a later priority.

Which of the following clients would be predisposed to developing a yeast-like Candida albicans fungal infection? A. A diabetic male child with circular patches on the arms B. An immunosuppressed cancer client with maculopapular satellite lesions C. A high school football player with fungal spores cultured on the feet D. A dance instructor with a rash on the hands described as raised borders

B In addition to microscopic analysis of skin scrapings for tinea fungal spores, a candidal infection often can be differentiated from a tinea infection by the presence of maculopapular satellite lesions found outside the clearly demarcated borders. Some persons are predisposed to candidal infections by conditions such as diabetes mellitus, antibiotic therapy, pregnancy, oral contraceptive use, poor nutrition, and immunosuppressive diseases. The most common types of tinea lesions are oval or circular patches with raised red borders consisting of vesicles, papules, or pustules on exposed skin surfaces.

A teenager reports ugly warts that have invaded her hands. She wants them gone before prom season. The nurse will likely be explaining which of the following treatment measures to this teenager? A. How to apply steroid creams and Band-Aids B. Applying a keratolytic agent like salicylic acid C. Taking a pair of tweezers and pulling the wart off D. How to safely use cryotherapy at home

B Verrucae, or warts, are common, benign papillomas caused by DNA-containing human papillomavirus (HPV) that invade the superficial skin keratinocytes. Removal is usually done by applying a keratolytic agent, such as salicylic acid, which works by dissolving intercellular cement and producing desquamation of the horny layer of skin without affecting normal epidermal cells. Steroid creams will not help with removal of a wart. Pulling the wart off is not recommended. Cryotherapy may be needed, but this is performed in a doctor's office.

The nurse caring for a client with a malignant melanoma should prepare the client for which of the following treatments? Select all that apply. A. Cosmetic surgery to remove the mole without leaving a scar B. Immediate radiation therapy to shrink the tumors C. Surgical excision with lymph node biopsy D. Biologic therapy with interferon alfa-2B

C, D Treatment of melanoma is usually surgical excision, the extent of which is determined by the thickness of the lesion, invasion into the deeper skin layers, and spread to the regional lymph nodes. Current capability allows for mapping lymph flow to a regional lymph node that receives lymphatic drainage from tumor sites on the skin. This lymph node, which is called the sentinel lymph node, is then sampled for biopsy. If tumor cells have spread from the primary tumor to the regional lymph nodes, the sentinel node will be the first node in which tumor cells appear. Therefore, sentinel node biopsy can be used to test for the presence of melanoma cells and determine if radical lymph node dissection is necessary. Interferon alfa-2b is a biologic therapy available for adjuvant treatment of melanoma.

A thermal burn described as involving the entire epidermis and dermis is classified as: A. Full third degree B. Deep first degree C. Partial second degree D. Full-thickness second degree

D Second-degree full-thickness burns involve the entire epidermis and dermis. First-degree burns (superficial partial-thickness burns) involve only the outer layers of the epidermis. Second-degree partial-thickness burns involve the epidermis and various degrees of the dermis. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve muscle and bone.

A client has been admitted to the intensive care unit of the hospital after developing toxic epidermal necrolysis (TEN) consequent to the administration of a sulfonamide antibiotic. What pathophysiologic phenomenon is likely the greatest immediate threat to this client's health? A. The development of bacterial cellulitis on compromised skin surfaces B. Fluid and electrolyte imbalances resulting from the loss skin integrity C. A cascading autoimmune response that may result in shock D. The presence of diffuse lesions and skin sloughing on the client's mucous membranes

D TEN is manifested by large areas of denuded skin resulting from separation at the basement membrane. This sloughing and necrosis can be fatal if it occurs in the airway and on the other mucous membranes. Infection and fluid and electrolyte imbalances may occur, but the most immediate threat results from the immediate consequences of skin sloughing. A cascading autoimmune response does not occur in TEN.

A child has been admitted to the burn unit after pulling a pan of hot water off the stove. Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply. A. Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments. B. Assess for indications that the child's airway has been compromised by assessing breath sounds and voice quality. C. Maintain sterile field when doing dressing changes and debridement. D. Withhold foods/nutrition since the GI tract may have slowed down in response to stress. E. Minimize pain medication administration to not compromise the child's respiratory effort.

A, B, C Fluid is lost from the vascular, interstitial, and cellular compartments. Because of a loss of vascular volume, major burn victims often present in the emergency department in a form of hypovolemic shock. Manifestations of inhalation injury include hoarseness, drooling and inability to handle secretions, hacking cough, and labored, shallow breathing. Immunologically, the skin is the body's first line of defense. When the skin is no longer intact, the body is open to bacterial infection. The stress of burn injury increases metabolic and nutritional requirements; therefore, nutrition should not be withheld. Pain medication should be titrated to the child's need.

A woman has just delivered a child with a hemangioma on his right cheek area. The mother clutches the nurse and asks, "What is that thing on his face?" The nurse will respond with which of the following facts? Select all that apply. A. "This is usually called a strawberry 'birth mark' and pretty common in newborns." B. "These hemangiomas may grow larger early on followed by a period where the growth is reversed." C. "Most of these hemangiomas will remain with the infant for the rest of his life. However, they are not cancerous." D. "If this birth mark develops ulceration, we will need to keep a close eye on it to prevent any infections." E. "We will keep a close watch on your infant's vision since they can develop malformation of the eye that could develop into glaucoma."

A, B, D Hemangiomas of infancy (formerly called strawberry hemangiomas) are small, red lesions that are noticed shortly after birth. Hemangiomas of infancy are generally benign vascular tumors produced by proliferation of endothelial cells. They are seen in approximately 10% of children in the first year of life. Hemangiomas of infancy typically undergo an early period of proliferation during which they enlarge, followed by a period of slow involution during which the growth is reversed until complete resolution. A small percentage of hemangiomas develop complications. Ulceration, the most frequent complication, can be painful and carries the risk of infection, hemorrhage, and scarring. Port-wine stains usually are confined to the skin but may be associated with vascular malformations of the eye, resulting primarily in glaucoma.

A client is exhibiting manifestations of superficial dermatophytosis of the skin with skin scaling and nail disintegration. Based on these findings, the nurse can anticipate that the client will be prescribed: Select all that apply. A. An antifungal like ketoconazole B. An antibiotic like tetracycline C. Topical corticosteroid D. An antihistamine like Benadryl

A, C The fungi that cause superficial mycoses are called dermatophytes and require keratin for growth. Therefore, these fungi do not infect deeper body tissues or mucosal surfaces. The dermatophytes emit an enzyme that enables them to digest keratin, which results in superficial skin scaling, nail disintegration, or hair breakage, depending on the location of the infection. The principal agents are the azoles (ketoconazole, miconazole, clotrimazole, etc.) and the allylamines (naftifine and terbinafine). Both act by inhibiting the synthesis of ergosterol, which is an essential part of fungal cell membranes. Topical corticosteroids may be used in conjunction with topical antifungal agents to relieve itching and erythema secondary to inflammation. Antibiotics are not effective for fungal infections, and antihistamines are usually reserved for itching, which is not characteristic of this disease.

Which of the following changes are normal in the elderly population? Select all that apply. A. The dermis and epidermis thin as one ages. B. An increase in the amount of subcutaneous tissue. C. A thickening of blood vessels. D. Increased amount of padding on the buttocks. E. Skin may become dry, rough, and scaly.

A, C, E Normal skin changes associated with aging are seen on areas of the body that have not been exposed to the sun. They include thinning of the dermis and the epidermis, diminution in subcutaneous tissue, and a decrease and thickening of blood vessels. These result in less padding and thinner skin, with color and elasticity changes. Although the reason is poorly understood, the skin in most elderly persons older than 70 years of age becomes dry, rough, scaly, and itchy.

A client has just received the diagnosis of malignant melanoma, stage 3B. He asks the nurse what this means. The nurse should respond relaying which of the following information? Select all that apply. A. Malignant melanoma is a very rapid growing, aggressive cancer. B. This cancer usually extends wide and deep but rarely metastasize. C. This cancer is mainly contained to the head and neck area. D. Your cancer has grown into the deep tissues and quite likely into lymph nodes (stage 3B).

A, D Although melanoma represents a small subset of skin cancers, it is the most deadly. It is a rapidly progressing, metastatic form of cancer. Malignant melanomas differ in size and shape. Usually, they are slightly raised and black or brown. Borders are irregular and surfaces are uneven. Most appear to arise from preexisting nevi or new mole-like growths. There may be surrounding erythema, inflammation, and tenderness. Because most melanomas initially metastasize to regional lymph nodes, additional information may be obtained through lymph node biopsy. Consistent with other cancerous tumors, melanoma is commonly staged using the TNM (tumor, lymph node, and metastasis) staging system. Basal cell cancer usually extends wide and deep but rarely metastasizes and are most frequently seen on the head and neck, most often occurring on skin that has hair.

Which of the following actions involves the greatest risk of skin shearing? A. Inserting a peripheral intravenous catheter B. Rolling the client from a supine to side-lying position C. Pulling the client up in bed D. Helping the client ambulate after surgery

C Shear occurs when the skeleton moves, but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed. Rolling a client, starting an IV catheter, or assisting with mobilization does not pose a risk of skin shearing.

Which of the following clinical manifestations would lead the health care provider to diagnose the sunburn as severe? A. Skin is red and warm to touch. B. Some peeling and itching occur several days after the initial burn. C. There is blistering of the skin and associated fever and chills. D. There is a pruritic rash over the sunburned skin area.

C Sunburn ranges from mild to severe. Mild sunburn consists of various degrees of skin redness. The burn continues to develop for 24 to 72 hours, occasionally followed by peeling skin in 3 to 8 days. Some peeling and itching may continue for several weeks. Inflammation, blistering, weakness, chills, fever, malaise, and pain often accompany severe forms of sunburn.

What process accounts for the damaging effects of the sun's radiation? A. Initiation of an autoimmune response B. Compensatory increases in melanin production C. Damage to epidermal cell DNA and free radical production D. Hyperkeratinization and the formation of microscopic, subcutaneous lesions

C Ultraviolet B (UVB) radiation is primarily responsible for sunburns, and it acts mainly on the cells in the basal layer of the epidermis, producing direct damage to the DNA and other nuclear proteins. It also provokes free radical production and induces a significant reduction in skin antioxidants, impairing the ability of the skin to protect itself against the free radicals that are generated. UV radiation does not provoke an autoimmune response or hyperkeratinization, although there is an inflammatory response. Increased melanin production is a protective mechanism and does not participate in the deleterious effects of UV radiation.

The clinic health care worker notices that a client has a fungal infection on her nails that looks like the fungus is digesting the nail keratin. The nail appears opaque and white in color. The client states she has had this for years. The health care worker suspects the client has: A. Candidiasis B. Cellulitis C. Onychomycosis D. Tinea corporis

C Onychomycosis often begins at the tip of the nail, where the fungus digests the nail keratin. Initially, the nail appears opaque, white, or silvery. The nail then turns yellow or brown and remains unchanged for years. Gradually, the nail thickens and cracks as the infection spreads. Candidiasis (moniliasis) is a fungal infection caused by C. albicans. This yeast-like fungus is a normal inhabitant of the gastrointestinal tract, mouth, and vagina. Cellulitis is a deeper infection affecting the dermis and subcutaneous tissues. The lesion consists of an expanding red, swollen, tender plaque with an indefinite border, covering a variety of widths. Cellulitis is frequently accompanied by fever, erythema, heat, edema, and pain. Tinea corporis (ringworm of the body) are oval or circular patches on exposed skin surfaces and the trunk, back, or buttocks.