Question 1

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?&#10;A) Several dry, scaly patches on the face&#10;B) Numerous varicosities noted on both legs&#10;C) Dilation of small blood vessels on the face&#10;D) Petechiae present on the chest and abdomen

Accepted Answer

Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies.The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up.The other skin changes are associated with aging.Although the other changes will also require ongoing monitoring or intervention by the nurse,they do not indicate a need for urgent action.

Question 2

When taking the health history of an older adult,the nurse discovers that the patient has worked in the landscaping business for 40 years.The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)?

A) Vitiligo
B) Alopecia
C) Intertrigo
D) Erythema
E) Actinic keratosis

Erythema
Actinic keratosis

Accepted Answer

A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo,alopecia,and intertrigo are not associated with excessive sun exposure.

Question 3

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot.Which items should the nurse gather for this procedure?&#10;A) Sterile gloves&#10;B) Patch test instruments&#10;C) Cotton-tipped applicators&#10;D) Local anesthetic, syringe, and intradermal needle

Accepted Answer

Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators.Sterile gloves are not needed because it is not a sterile procedure.Local injection is not needed because the swabbing is not usually painful.The patch test is done to determine whether a patient is allergic to specific testing material,not for obtaining fungal specimens.

Question 4

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?&#10;A) Reports a history of allergic rashes&#10;B) Scattered macular brown areas on extremities&#10;C) Skin brown and wrinkled, skin tenting on forearm&#10;D) Longitudinal nail bed ridges noted; sparse scalp hair

Accepted Answer

Because the patient will be receiving antibiotics to treat the pneumonia,the nurse should be most concerned about her history of allergic rashes.The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs,especially antibiotics.The assessment data in the other response would be normal for an older patient.

Question 5

The nurse assesses a circular,flat,reddened lesion about 5 cm in diameter on a middle-aged patient's ankle.How should the nurse determine if the lesion is related to intradermal bleeding?&#10;A) Elevate the patient's leg.&#10;B) Press firmly on the lesion.&#10;C) Check the temperature of the skin around the lesion.&#10;D) Palpate the dorsalis pedis and posterior tibial pulses.

Accepted Answer

If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause,the discoloration will remain when direct pressure is applied to the lesion.If the lesion is caused by blood vessel dilation,blanching will occur with direct pressure.The other assessments will assess circulation to the leg,but will not be helpful in determining the etiology of the lesion.

Question 6

A patient reports chronic itching of the ankles and continuously scratches the area.Which assessment finding will the nurse expect?&#10;A) Hypertrophied scars on both ankles&#10;B) Thickening of the skin around the ankles&#10;C) Yellowish-brown skin around both ankles&#10;D) Complete absence of melanin in both ankles

Accepted Answer

Lichenification is likely to occur in areas where the patient scratches the skin frequently.Lichenification results in thickening of the skin with accentuated normal skin markings.Vitiligo is the complete absence of melanin in the skin.Keloids are hypertrophied scars.Yellowish-brown skin indicates jaundice.Vitiligo,keloids,and jaundice do not usually occur as a result of scratching the skin.

Question 7

During assessment of the patient's skin,the nurse observes a similar pattern of small,raised lesions on the left and right upper back areas.Which term should the nurse use to document these lesions?&#10;A) Confluent&#10;B) Zosteriform&#10;C) Generalized&#10;D) Symmetric

Accepted Answer

The description of the lesions indicates that they are grouped.The other terms are inconsistent with the description of the lesions.

Question 8

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN)(select all that apply)?&#10;A) Administer patch testing to a patient with allergic dermatitis.&#10;B) Interview a new patient about chronic health problems and allergies.&#10;C) Apply a sterile dressing after the health care provider excises a mole.&#10;D) Teach a patient about site care after a punch biopsy of an upper arm lesion.&#10;E) Explain potassium hydroxide testing to a patient with a superficial skin infection.

Accepted Answer

Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice.Obtaining a health history and patient education require more critical thinking and registered nurse (RN)level education and scope of practice.

Question 9

When examining an older patient in the home,the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body.Which action should the nurse take first?&#10;A) Discourage the use of throw rugs throughout the house.&#10;B) Ensure the patient has a pair of shoes with non-slip soles.&#10;C) Talk with the patient alone and ask about what caused the bruising.&#10;D) Notify the health care provider so that x-rays can be ordered as soon as possible.

Accepted Answer

The nurse should note irregular patterns of bruising,especially in the shapes of hands or fingers,in different stages of resolution.These may be indications of other health problems or abuse,and should be further investigated.It is important that the nurse interview the patient alone because,if mistreatment is occurring,the patient may not disclose it in the presence of the person who may be the abuser.Throw rugs and shoes with slippery surfaces may contribute to falls.X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility.However,the nurse's first nursing action is to further assess the patient.

Question 10

A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face.Which additional assessment information will be most important for the nurse to obtain?

A) History of sun exposure by the patient
B) Method of birth control used by the patient
C) Length of time the patient has used fluorouracil
D) Appearance of the treated areas on the patient's face

Accepted Answer

Because fluorouracil is teratogenic,it is essential that the patient use a reliable method of birth control.The other information is also important for the nurse to obtain,but lack of reliable birth control has the most potential for serious adverse medication effects.

Question 11

A dark-skinned patient has been admitted to the hospital with chronic heart failure.How would the nurse best assess this patient for cyanosis?&#10;A) Assess the skin color of the earlobes.&#10;B) Apply pressure to the palms of the hands.&#10;C) Check the lips and oral mucous membranes.&#10;D) Examine capillary refill time of the nail beds.

Accepted Answer

The answer of A dark-skinned patient has been admitted to...

Question 12

A patient 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 patient for which type of biopsy?&#10;A) Shave biopsy&#10;B) Punch biopsy&#10;C) Incisional biopsy&#10;D) Excisional biopsy

Accepted Answer

The answer of A patient in the dermatology clinic is...

Question 13

When performing a skin assessment,the nurse notes several angiomas on the chest of an older patient.Which action should the nurse take next?&#10;A) Assess the patient for evidence of liver disease.&#10;B) Discuss the adverse effects of sun exposure on the skin.&#10;C) Teach the patient about possible skin changes with aging.&#10;D) Suggest that the patient make an appointment with a dermatologist.

Accepted Answer

The answer of When performing a skin assessment,the nurse notes...

Deck 19: Nursing Assessment: Integumentary System