Question 1

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area.The nurse examines the pressure ulcer and determines that it is a stage II ulcer.Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.

Accepted Answer

Stage I pressure ulcers have intact skin that appears red but not broken,and localized redness in intact skin will blanche with fingertip pressure.Stage II pressure ulcers have partial thickness skin erosion with loss of epidermis or also the dermis,and open blisters have a red-pink wound bed.Stage II pressure ulcers are full thickness,extending into the subcutaneous tissue;subcutaneous fat may be seen but not muscle,bone,or tendon.Stage IV pressure ulcers involve all skin layers and extend into supporting tissue,exposing muscle,bone,and tendon.Slough (stringy matter attached to the wound bed)or eschar (black or brown necrotic tissue)may be present.

Question 2

A 40-year-old woman reports a change in mole size,accompanied by color changes,itching,burning,and bleeding over the past month.She has a dark complexion and has no family history of skin cancer,but she has had many blistering sunburns in the past.The nurse would:

Accepted Answer

The ABCD danger signs of melanoma are asymmetry,border irregularity,color variation,and diameter.In addition,individuals may report a change in size,development of itching,burning,bleeding,or a new-pigmented lesion.Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.

Question 3

The nurse is assessing for inflammation in a dark-skinned person.Which is the best technique?

Accepted Answer

Because you cannot see inflammation in dark-skinned persons,it is often necessary to palpate the skin for increased warmth,taut or tightly pulled surfaces that may be indicative of edema,and hardening of deep tissues or blood vessels.

Question 4

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin.Which of the following definitions are correct? Select all that apply.

Accepted Answer

An elevated,circumscribed lesion filled with turbid fluid (pus)is a pustule.A hypertrophic scar is a keloid.A bulla is larger than 1 cm and contains clear fluid;a papule is solid,elevated,but less than 1 cm.

Question 5

A 52-year-old woman has a papule on her nose that has rounded,pearly borders and a central red ulcer.She said she first noticed it several months ago and that it has slowly grown larger.The nurse suspects which condition?

Accepted Answer

Basal cell carcinoma usually starts as a skin-colored papule that develops rounded,pearly borders with a central red ulcer.It is the most common form of skin cancer,and it grows slowly.This description does not fit acne lesions.See Table 12-11 for descriptions of malignant melanoma and squamous cell carcinoma.

Question 6

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease,the nurse notices the presence of pitting edema in the lower legs bilaterally.The skin is puffy and tight but of normal color.There is no increased redness or tenderness over his lower legs,and the peripheral pulses are equal and strong.In this situation,the nurse suspects that the likely cause of the edema would be:

Accepted Answer

Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure.Unilateral edema usually has a local or peripheral cause.

Question 7

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen.Her face,nail beds,lips,and oral mucosa are a bright cherry-red color.The nurse suspects that this coloring is due to:

Accepted Answer

A bright cherry-red coloring in the face,upper torso,nail beds,lips,and oral mucosa appears in cases of carbon monoxide poisoning.

Question 8

A patient has been admitted for severe psoriasis.The nurse can expect to see what finding in the patient's fingernails?

Accepted Answer

Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment,and they are associated with psoriasis.See Table 12-13 for descriptions of the other terms.

Question 9

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours.He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours.The nurse suspects dehydration.The nurse should test skin mobility and turgor in this infant over the:

Accepted Answer

Test mobility and turgor over the abdomen in an infant.Poor turgor,or "tenting," indicates dehydration or malnutrition.The other areas are not appropriate sites for checking skin turgor in an infant.

Question 10

The nurse is assessing a patient who has liver disease for jaundice.Which of these assessment findings is indicative of true jaundice?

Accepted Answer

The yellow sclera of jaundice extends up to the edge of the iris.Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice.Do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

Question 11

The nurse is assessing for clubbing of the fingernails and would expect to find:

Accepted Answer

The normal nail is firm at its base and has an angle of 160 degrees.In clubbing,the angle straightens to 180 degrees or greater and the nail base feels spongy.

Question 12

A few days after a summer hiking trip,a 25-year-old man comes to the clinic with a rash.On examination,the nurse notes that the rash is red,macular,with a bull's eye pattern across his midriff and behind his knees.The nurse suspects:

Accepted Answer

Lyme disease occurs in people who spend time outdoors in May through September.The first state has the distinctive bull's eye,a red macular or papular rash that radiates from the site of the tick bite with some central clearing,5 cm or larger,usually in the axilla,midriff,inguina,or behind the knee,with regional lymphadenopathy.

Quiz 12: Skin, Hair, and Nails