Deck 12: The Integument

Question 1

The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. The nurse would suspect the physician to diagnose this condition as:
1) Actinic keratosis
2) Basal cell carcinoma
3) Malignant melanoma
4) Squamous cell carcinoma

Answer 1

4

Question 2

An older patient has a subnormal body temperature and an infection. How does the nurse best describe this phenomenon?
1) The temperature regulating mechanism deteriorates with aging.
2) The patient's infection is improving with medication treatment.
3) The diagnosis of an infection is inaccurate and will be checked.
4) The temperature was obtained incorrectly and is inaccurate.

Answer 2

1

Question 3

An older patient is recovering from surgery to repair a fractured hip. What interventions will the nurse use to prevent the development of a pressure ulcer in this patient? Select all that apply.
1) Avoid sitting unless for meals.
2) Use pillows to protect the skin.
3) Reposition the patient every 2 hours.
4) Keep the skin dry with frequent bathing.
5) Encourage independent position changes.

Answer 3

1, 2, 3, 5

Question 4

An older patient has a Braden Scale pressure ulcer risk score of 18. What interventions would be indicated by the nurse?
1) Provide routine skin care with soap and water daily.
2) Inspect skin when repositioning, toileting, and assisting with ADLs.
3) Avoid the use of pillows and foam slabs between bony prominences.
4) Provide routine activities, score is not concerning.

Question 5

An older patient is recovering from abdominal surgery. Which interventions will the nurse consider when planning care for this patient?
1) The wound should be kept covered with an antimicrobial dressing.
2) The wound dressing should be changed daily and kept dry.
3) There is a need to keep the wound edges taped.
4) Skin near the wound needs to be massaged to increase blood flow.

Question 6

The nurse is preparing to cleanse an older patient's pressure injury. Which techniques should the nurse use to perform this action? Select all that apply.
1) Pour saline over the wound using a saline-filled syringe.
2) Apply saline-soaked gauze over the wound.
3) Apply hydrogen peroxide over the wound.
4) Place gauze pads soaked with Dakin's solution on the wound.
5) Apply dry gauze pads over the wound and saturate with sterile water.

Question 7

An older patient complains about increasing dry skin. What should the nurse explain to the patient about this skin problem? Select all that apply.
1) There is a reduction in sebum production as the body ages.
2) There is a decrease in the number of sweat glands in the body with aging.
3) There is a change in the keratinization and lipid content in the stratum corneum.
4) There is an increase in body core temperature with aging, resulting in skin drying.
5) There is a change in the structure of the skin cell because of years of using alcohol-based soaps.

Question 8

The nurse is assessing an older patient's stage III pressure ulcer. What would be indicative of proper wound healing?
1) An increase in wound depth
2) Large amount of undermining
3) Presence of leathery black tissue
4) Beefy red and moist, grainy appearance

Question 9

The nurse is caring for an older patient diagnosed with melanoma of the nail. What might the nurse find during the physical assessment? Select correct answer.
1) Decreased skin thickness around the nail beds.
2) A sore, rough, scaly, reddened papule around the nails.
3) A longitudinal pigmented band.
4) Indurated scaly plaques, papules, or nodules near the nail bed.

Question 10

After an assessment the nurse is concerned that an older patient is at risk for pressure ulcer development because of the current nutritional status. What nutritional factors did the nurse assess in the patient? Select all that apply.
1) Diagnosis of dehydration
2) Hemoglobin level 9 mg/dL
3) Treatment for chronic renal failure
4) Serum albumin level below normal
5) Loss of 20 pounds over the last 3 months

Question 11

The nurse is teaching assisted living center residents about over-the-counter skin preparations. Which should be used with caution in an older patient? Select all that apply.
1) Sunblock SPF 50
2) Super-fatted soaps
3) Emollients that keep the skin moist
4) Steroid-based ointments and creams
5) Topical lotion with an antihistamine

Question 12

What instruction should the nurse provide to a nursing assistant who is assigned to care for an older patient with a stage I pressure injury on the right heel?
1) Apply a dry dressing to the site.
2) Apply a donut under the right heal.
3) Cleanse the area with tepid water.
4) Keep the head of the bed elevated.

Question 13

An older patient recently diagnosed with skin cancer does not understand why the disease developed since sunbathing has always been avoided. How should the nurse respond to this patient?
1) "Can you tell me more about your feelings?"
2) "Sun exposure can happen from driving a car."
3) "We frequently never find out why cancer strikes."
4) "This is unusual, as skin cancer normally only occurs in sunbathers."

Question 14

The nurse is caring for an older patient who has a healed, sacral pressure ulcer. What would the nurse include in teaching about this new tissue growth?
1) "Your sacral area will heal faster if reinjured."
2) "Your skin will break down faster if your sacrum is reinjured."
3) "You may have a loss of feeling in the old, pressure ulcer area."
4) "You are more at risk for infection in the sacral area."

Question 15

The nurse is performing a skin assessment on an older African American patient. Which findings would be considered normal for this patient? Select all that apply.
1) Xerosis
2) Many small, dark papules on the face
3) Hard, smooth purple area on the upper arm
4) Multiple skin tears with clear fluid drainage
5) Freckle-like pigmentation of the tongue borders

Question 16

The nurse provides a seminar on the impact of the sun on the skin with a group of older community members. Which statement indicates the older clients understood the education?
1) "It is important to wear sunscreen all the time."
2) "The sun should be avoided at all times."
3) "African Americans can not experience sun damage."
4) "The melanocytes in the subcutaneous tissue protect the skin from sun damage."

Question 17

The home-care nurse determines that their patient is at risk for further injury due to normal aging sensation loss when they state the following:
1) "I have this large red mark on my arm and I think it occurred yesterday from cooking."
2) "I can't remember what I ate for lunch yesterday."
3) "I got a small cut on my arm from a zipper when I was getting dressed yesterday."
4) "I have some discolorations on my arm, but they have been there for months."

Question 18

The nurse is preparing discharge instructions for an older patient. If the patient is prescribed Ibuprofen, what should the nurse specifically educate the patient about? Select correct answer.
1) The nurse should teach the patient that they may experience a pimply rash on their arms.
2) The nurse should teach the patient that they may experience blue pigmentation.
3) The nurse should teach the patient to avoid extended sun exposure.
4) The nurse should teach the patient that he/she may be at risk for skin melanomas.

Question 19

An older patient requests a small, inflated donut to sit on to relieve pressure. What response by the nurse is appropriate?
1) "Ok, it will definitely help with relieving pressure."
2) "Using the donut can cause skin breakdown."
3) "I will need to obtain an order from the physician for you."
4) "I will give it to your wife and you can use this at home."

Question 20

The daughter of an older patient sees a reddened area on the patient's coccyx and wants to massage the area to improve circulation. What response by the nurse is indicated?
1) "I will record these findings in the medical record."
2) "I will need to obtain an order from the physician to perform a massage."
3) "Massaging the area twice a day would help circulation."
4) "It is best to hydrate the skin with a moisturizer."

Question 21

An older patient has a stage III pressure ulcer. Which treatment would the nurse expect the physician to order for the patient's wound?
1) Cadexomer
2) Silver sulfadiazine
3) Nanocrystalline silver
4) Topical antibiotic cream

Question 22

The nurse is caring for an older patient with a stage II pressure ulcer. The nurse suspects this stage of wound will likely need to be cleaned with:
1) Saline
2) Dakin's solution
3) Povidone-iodine
4) Hydrogen peroxide

Question 23

Which actions would the nurse take to prevent skin tears on an older patient with friable skin? Select all that apply.
1) Avoid harsh soaps.
2) Apply silk tape over dressings.
3) Ensure an adequate fluid intake.
4) Use a lift sheet to reposition in bed.
5) Apply skin-moisturizing cream to arms and legs twice a day.

Question 24

The nurse is planning care for an older patient with pneumonia and a stage II pressure ulcer. Which nursing diagnosis would have the greatest priority for this patient's care?
1) Acute Pain related to destruction of tissue
2) Knowledge Deficit related to care of skin disorder
3) Risk for Infection related to impaired skin integrity
4) Potential for Infection related to impaired skin integrity

Question 25

The nurse is treating a skin tear on an older patient's lower leg. Which dietary selection contains ingredients that will be most favorable to wound healing for this patient?
1) Cereal, milk, and toast
2) Bacon, toast, and coffee
3) Eggs, toast, and orange juice
4) Ham slices, milk, and applesauce