Question 1

The nurse is conducting an integumentary assessment on an older adult. Which patient statement would the nurse prioritize as it does not reflect a normal age-related change?

Accepted Answer

Older adults often experience thinning skin, slower nail growth, and graying hair as a normal age-related change. However, excessively oily skin in an older adult may indicate an underlying condition or medication side effect that requires further assessment.

Question 2

During a physical exam of the patient's nails, the nurse depresses the nail edge to blanch it, and then releases it. What is the nurse assessing with this technique?

Accepted Answer

The nurse is assessing capillary refill. Depressing the nail edge causes blanching, and releasing it allows for observation of the return of pink color as blood flow returns to the capillaries. This gives information on the adequacy of peripheral circulation. This technique does not assess for clubbing, nail attachment, or nail strength.

Question 3

A patient has been admitted with damage to the skin over both lower legs. The nurse immediately institutes measures to help prevent infection. The nurse's rationale for this action relates to damage of which cells? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

B,C,D

Question 4

A patient is very concerned about a vesicle on the lip that extends onto the skin. The patient's history reveals this vesicle has been present for 3 days. Which assessment question would the nurse ask?

Accepted Answer

Vesicles on the lip that extend onto the skin are most commonly caused by herpes simplex virus (HSV) infection, which can cause cold sores. Asking about a history of cold sores or herpes infections can help with identifying the cause of the vesicle. Questions about pets, family history of skin cancer, and dehydration are not relevant to the assessment of this particular vesicle.

Question 5

The nurse discovers a vascular lesion on a patient's chest. What should the nurse check to help determine if the lesion is petechiae or telangiectasia?

Accepted Answer

Checking if the lesion blanches (loses color briefly when pressure is applied) can help determine if it is petechiae (which will not blanch) or telangiectasia (which will blanch). The other options do not necessarily distinguish between the two types of lesions.

Question 6

A patient is admitted with edematous lower extremities. The nurse palpates the patient's skin and finds that when pressure is applied, a deep indentation occurs and lasts for a short time. The nurse would document this finding as ____ + pitting edema.

Accepted Answer

The answer of A patient is admitted with edematous lower...

Question 7

How should the nurse conduct the physical examination of a patient's skin?

Accepted Answer

The nurse should be aware of ethnic differences in skin color and patterns to avoid misinterpreting normal variations as abnormalities.

Question 8

During a conversation with the nurse, a patient says, "I avoid going outside when the sun is shining because I don't want to get skin cancer." The nurse should inform the patient that sun avoidance may predispose the patient to which condition?

Accepted Answer

Sunlight exposure is essential to the body's production of vitamin D. Avoiding sunlight can increase risk for vitamin D deficiency, which can lead to a variety of other health problems.

Question 9

A patient from Southeast Asia who has been ill with influenza is admitted with self-inflicted open sores and bruising on both forearms. When questioned about the wounds, the patient states that they were inflicted to aid the healing process. What should the nurse consider when assessing these wounds?

Accepted Answer

In some Southeast Asian cultures, it is believed that creating open wounds can help to release toxins from the body and aid in the healing process. It is important for the nurse to understand and respect cultural practices while also assessing the wounds for any signs of infection or self-harm.

Question 10

The emergency department nurse palpates a patient's skin to assess its texture. The nurse manager would evaluate that this nurse is following protocol if which technique is used?

Accepted Answer

Palpating the skin with the palmar surface of the fingers and finger pads is the recommended technique for assessing skin texture. This allows the nurse to feel for any irregularities in the skin's surface, such as roughness or smoothness. The other options (using the dorsal surface of the hand, placing the palm of the hand on the skin, or using the anterior surface of the wrist) are not as effective in assessing skin texture.

Question 11

After assisting a patient to turn in bed, the nurse notes that the patient's leg has indentations that clearly show where the leg was supported by the nurse's hand. How would the nurse document this finding?

Accepted Answer

Pitting edema is characterized by a visible indentation or pit in the skin when pressure is applied, which is what the nurse observed on the patient's leg. Loss of skin elasticity and increased skin turgor are not related to this finding, and reduced sensation would not manifest as an indentation in the skin.

Question 12

Which information would the nurse identify as a patient's chief complaint about a skin disorder?

Accepted Answer

The patient's chief complaint is usually a brief statement describing the main reason for seeking medical attention. Option B states the location of the rash, which can be identified as the chief complaint. The other options provide additional information but do not clearly identify the chief complaint.

Question 13

Which technique would the nurse use to assess a patient's skin turgor?

Accepted Answer

Grasping a fold of the patient's skin between the forefinger and thumb is the technique used to assess skin turgor. The nurse would lift the skin and release it, observing how quickly it returns to its normal position, which helps evaluate hydration status. Palpating the skin is a general technique used to assess temperature, texture, moisture, and integrity, but not skin turgor specifically. Determining fluid intake is important information to gather, but does not assess skin turgor. Blanching the nail bed is a technique used to assess capillary refill, not skin turgor.

Question 14

The nurse notes a yellowish discoloration of the patient's skin, but it does not involve the sclera or mucous membranes. The nurse should question the patient about which history?

Accepted Answer

A yellowish discoloration of the skin without involvement of the sclera or mucous membranes may suggest carotenemia, which is often related to dietary intake, particularly high consumption of foods rich in carotene like carrots and sweet potatoes.

Question 15

During completion of a health history, the patient reports being allergic to strawberries. What additional questions should the nurse ask? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of During completion of a health history, the...

Question 16

A patient with a history of chronic allergic dermatitis is concerned because of an area where the skin has become thickened and rough. How would the nurse document this lesion?

Accepted Answer

Lichenification is the thickening and roughening of the skin due to chronic irritation, such as from chronic allergic dermatitis. Excoriation refers to a loss of skin layers due to scratching or rubbing, ulceration refers to an open sore, and ecchymosis refers to a bruise.

Question 17

While recording the health history, the nurse learns that a patient has worked at a landfill for the last 35 years. Why is this information important?

Accepted Answer

Working at a landfill for an extended period may lead to exposure to environmental toxins, which can have negative effects on the patient's health. This information can be important to determine any potential health issues that may arise from this exposure.

Question 18

While palpating the nail bed of an African American patient, the nurse notes that the nails have linear bands along the nail edge. How would the nurse evaluate this finding?

Accepted Answer

Linear bands along the nail edge in dark-skinned individuals are a common finding and usually do not indicate any pathology. This is known as longitudinal melanonychia and is due to an increased production of pigment by the nail matrix cells. However, if the bands are irregular, asymmetrical, or accompanied by other symptoms such as changes in the nail shape or size, it may warrant further evaluation for conditions such as melanoma or fungal infections.

Question 19

While performing the assessment for bilateral symmetrical skin temperature, the nurse finds that the skin temperature of the patient's left hand is much cooler than the skin temperature of the right hand. The nurse should conduct additional assessment for which possible conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of While performing the assessment for bilateral symmetrical...

Question 20

A 50-year-old patient is concerned because several firm, deep-red papules have appeared on both legs and the number is increasing. The nurse should recognize these as which type of lesion?

Accepted Answer

Cherry angiomas are small, firm, red papules that commonly appear on the trunk, arms, and legs of middle-aged and older adults. They are not a cause for concern and do not require treatment. Venous stars are bluish, star-shaped lesions that are commonly seen on the legs in individuals with venous insufficiency. Purpura are purple, non-blanching lesions that are caused by bleeding into the skin. Spider angiomas are red, spider-like lesions with a central red spot and radiating arms, typically seen on the face and neck.

Quiz 58: Nursing Assessment of the Patient With Integumentary Disorders