Question 1

The nurse is caring for a client in the dermatology clinic who is scheduled for removal of a 15-mm multicoloured and irregular mole from the upper back. Which of the following biopsies would the nurse teach to this client?

A)Shave
B)Punch
C)Incisional
D)Excisional

Incisional

Accepted Answer

An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant; a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy.
Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

Question 2

The nurse is conducting a health history with a client and the nurse discovers that the client works as a roofer. The nurse will plan to teach the client about how to self-assess for clinical manifestations of which of the following integument conditions? (Select all that apply.)

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

Wrinkling
Erythema
Actinic keratosis

Accepted Answer

A client who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.

Question 3

The nurse is conducting a health assessment on an older-adult client and is assessing the client's nails. Which of the following assessments are age-related changes? (Select all that apply.)&#10;A)Longitudinal ridging&#10;B)Decreased keratin&#10;C)Decreased circulation&#10;D)Thick, brittle nails&#10;E)Increased peripheral blood supply &#10;

Accepted Answer

Age-related changes to the nails include a decreased peripheral blood supply and circulation, increased keratin, thick, brittle nails, longitudinal ridging and a prolonged return of blood to nails on blanching.

Question 4

The nurse is preparing for a teaching session with older-adult clients. Which of the following changes is an age-related change in the hair?&#10;A)Increased melanocytes&#10;B)Decreased oils&#10;C)Increased density&#10;D)Increased estrogen

Accepted Answer

Age-related changes to the hair include decreased oils, density, estrogen, and melanocytes.

Question 5

The nurse is conducting an assessment of the client's skin and observes a ring of small, raised, discrete lesions filled with serous fluid on the client's right temple. Which of the following descriptions would the nurse use when documenting the lesions?

A)Grouped
B)Confluent
C)Zosteriform
D)Generalized

Accepted Answer

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

Question 6

The nurse is caring for a client who reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for which of the following conditions?

A)Skin atrophy
B)Lichenification
C)Skin varicosity
D)Keloid formation

Accepted Answer

Lichenification is likely to occur in areas where the client scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.

Question 7

The nurse is caring for a client who has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. Which of the following actions would the nurse implement to determine whether the lesion is related to blood vessel dilation?

A)Elevate the client's leg
B)Press firmly on the lesion
C)Check the temperature of the skin around the lesion
D)Palpate the dorsalis pedis and posterior tibial pulses

Accepted Answer

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 8

The nurse is admitted an older-adult client to an assisted-living facility and notes abnormalities on the skin. Which of the following abnormalities is the priority to discuss immediately with the health care provider?

A)Several dry, scaly patches on the face
B)Numerous varicosities noted on both legs
C)Dilation of small blood vessels on the face
D)Petechiae present on the chest and abdomen

Accepted Answer

Petechiae are caused by pinpoint hemorrhages and are associated with inflammation, marked dilation, blood vessel trauma, and blood dyscrasia that results in bleeding tendencies (e.g., thrombo-cytopenia). The nurse should contact the client's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

Question 9

Which assessment information documented in a client's chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old client admitted with bacterial pneumonia?&#10;A)&#34;Scattered macular brown areas on extremities&#34;&#10;B)&#34;Skin brown and wrinkled, skin tenting on forearm&#34;&#10;C)&#34;Longitudinal nail bed ridges noted, sparse scalp hair&#34;&#10;D)&#34;Skin moist and intact, states history of allergic rashes&#34;

Accepted Answer

Because the client will be receiving antibiotics, the nurse should monitor the client for the presence of an allergic rash. The assessment data in the other response would be normal for an elderly client.

Question 10

The nurse is caring for a client who has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. Which of the following actions would the nurse implement to determine whether the lesion is related to blood vessel dilation?

A)Elevate the client's leg
B)Press firmly on the lesion
C)Check the temperature of the skin around the lesion
D)Palpate the dorsalis pedis and posterior tibial pulses

Accepted Answer

Angiomas are a common occurrence as client's age, but they may occur with systemic problems such as liver disease. The client may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the client about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.

Question 11

Aclient asks the nurse why a potassium hydroxide test needs to be done. The nurse's response is based upon the knowledge that which of the following is the purpose of this test?&#10;A)Examine a lesion via a biopsy.&#10;B)Obtain fluids from vesicles for assessment.&#10;C)Assess for fungal infection.&#10;D)Scrap exudate from a lesion for microscopic examination.

Accepted Answer

The answer of Aclient asks the nurse why a potassium...

Question 12

The nurse is caring for a client who is dark-skinned and has been admitted to the hospital in severe respiratory distress. Which of the following actions should the nurse implement to determine whether the client is cyanotic?

A)Assess the skin colour of the earlobes.
B)Apply pressure to the palms of the hands.
C)Check the lips and oral mucous membranes.
D)Examine capillary refill time of the nail beds.

Accepted Answer

The answer of The nurse is caring for a client...

Deck 25: Nursing Assessment Integumentary System