Question 1

The nurse notes a thickening and hardening of the skin from continued irritation on an individual who is wheelchair-bound.What term should the nurse use to describe this finding?

Accepted Answer

Lichenification is thickened,hardened skin.A.A crust is a scab formed by dried serum.B.A papule is a raised solid lesion.C.Excoriation is a traumatic abrasion.

Question 2

The nurse notes small (less than 0.5 cm),raised areas that contain serous fluid on a patient's arm.What term should the nurse use to document this finding?

Accepted Answer

A vesicle is a small fluid-filled blister.C.A macule is a flat change in color usually less than 1 cm.B.A papule is a solid raised lesion.A.A cyst is a closed sac or pouch.

Question 3

While inspecting the skin of a patient's arm the nurse notes lesions that are clustered together.How should the nurse document this finding?

Accepted Answer

Grouped lesions are clustered together.A.Linear lesions form a line.B.Discrete lesions are individual,separate,and distinct.D.Confluent lesions merge so that discrete lesions are not visible or palpable.

Question 4

The nurse is reviewing the functions and purpose of the skin with a group of high school students.From what source should the nurse explain that the epidermis receives its nourishment?

Accepted Answer

The epidermis is made of stratified squamous epithelial tissue and is avascular,meaning that it has no capillaries within it.Its nourishment comes from the dermis beneath it.B.Melanocytes are cells in the lower epidermis that produce the protein melanin.C.Epithelial cells are within the epidermis,D.The epidermis does not have its own blood supply.

Question 5

While collecting data on a patient,the nurse observes that the patient's facial skin is yellowish.What other area should the nurse assess to confirm presence of jaundice?

Accepted Answer

Although skin is affected by jaundice,the best place to inspect for jaundice is in the sclera of the eye.B.C.D.The best places to inspect for cyanosis are the lips,nail beds,conjunctivae,and palms.

Question 6

A patient is experiencing a fever.What structure should the nurse expect to provide an effective cooling mechanism for the body?

Accepted Answer

Eccrine glands are found throughout the dermis but are most numerous on the face,palms,and soles.They are activated by high temperatures or by exercise and secrete sweat onto the skin surface.The sweat is evaporated by excess body heat,which is a very effective cooling mechanism,although it does have the potential to lead to dehydration if water is not replaced by drinking.C.Subcutaneous adipose tissue cushions some bones and provides some insulation from cold,but its most important function is energy storage.D.Modified sweat glands called ceruminous glands are found in the dermis of the ear canals.Their secretion is called cerumen or earwax.A.Capillaries may dilate to release heat however this is not the most effective cooling mechanism in the body.

Question 7

The nurse is caring for a patient in a wound clinic who is treated with plastic wrap dressings.Which findings indicate complications related to prolonged application of the dressings? (Select all that apply.)

Accepted Answer

Continued use of occlusive dressings can cause skin atrophy,folliculitis,maceration,erythema,and systemic absorption of the medication.To prevent some of these complications,the dressing is removed for 12 out of every 24 hours.A.E.F.Properly applied occlusive dressings do not cause cyanosis,lichenification,or hyperpigmentation.

Question 8

During report,the nurse is told that a patient "has moderate jaundice." Which assessment finding should the nurse expect to see?

Accepted Answer

Jaundice,a yellow-orange discoloration,may occur as a result of liver disease.D.Cyanosis presents as a gray cast to the skin related to poor oxygenation.A.Erythema is red or purple gray.B.Pallor is paleness.

Question 9

A patient with cancer is experiencing hair loss from chemotherapy treatments.Which term should the nurse use to document this finding?

Accepted Answer

Hair loss is called alopecia.B.Allopathy is a system of medicine.C.Ecchymosis is bruising.D.Keratopenia is not a medical term.

Question 10

The nurse is applying a medicated plastic wrap dressing to a patient's leg.What intervention should the nurse include in the plan of care to prevent development of complications?

Accepted Answer

Plastic wrap dressings should be used for no more than 12 hours a day.Wet dressings and ointments should be applied only to affected areas,not to healthy intact skin,because this can cause maceration of good skin.A.B.D.These are inappropriate interventions to prevent a complication from the use of a dressing with a plastic wrap.

Question 11

The nurse is assisting a patient who has a suspected diagnosis of tinea capitis (ringworm).For which diagnostic test should the nurse prepare the patient?

Accepted Answer

Wood's light examination is the use of ultraviolet rays to detect fluorescent materials in the skin and hair present in certain diseases such as tinea capitis (ringworm).A.B.Patch and scratch tests are performed when allergic contact dermatitis is suspected.C.A skin biopsy is indicated for deeper infections to establish an accurate diagnosis or for the evaluation of current treatment.A biopsy is an excision of a small piece of tissue for microscopic assessment.

Question 12

The nurse is documenting findings from collecting data with a patient.What term should the nurse use to document transverse depressions in the nails?

Accepted Answer

Transverse depressions in the nails are called Beau's lines.D.Splinter hemorrhages are red or brown streaks in the nail bed.A.Paronychia is inflammation at the base of the nail.C.Koilonychias is concave nails.

Question 13

The nurse notices small purplish dots on the abdomen of a patient.Which statement should the nurse use to document the finding?

Accepted Answer

Petechiae are small reddish purple hemorrhagic spots,smaller than 0.5 mm in diameter.C.Ecchymosis is bruising.A.Erythema is redness.B.Purpura is bleeding into the skin.

Question 14

The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion.Which assessment finding should cause the nurse the most concern?

Accepted Answer

Wet dressings should not be prescribed for more than 72 hours,because the skin may become too dry or macerated.A.C.D.Oiliness,edema,and oozing are not common reactions to wet dressings.

Question 15

After a health interview the nurse is concerned that a patient might develop vitamin D deficiency.What information did the nurse use to come to this conclusion?

Accepted Answer

One function of the skin is the formation of vitamin D from cholesterol when the skin is exposed to the UV rays of the sun.Having no sun exposure can increase this patient's risk of developing a vitamin D deficiency.A.Spending time in the sun reduces this patient's risk of a vitamin D deficiency.B.D.Use of emollients and restricting caffeine will not adversely affect the patient's vitamin D level.

Question 16

After completing data collection the nurse determines that an older patient is experiencing the death of melanocytes.What observation did the nurse use to make this determination?

Accepted Answer

With aging the hair follicles become inactive and melanocytes die leading to gray and thin hair.A.Dry skin is caused by less active sebaceous glands.B.Wrinkled skin is caused by less active sebaceous glands and deterioration of collagen and elastin fibers.D.Thin and fragile skin is caused by slowing of epidermal cell division.

Question 17

The nurse is noting the texture of a patient's skin and hair.Which secretion should the nurse identify that prevents drying of skin and hair?

Accepted Answer

Most ducts of sebaceous glands open into hair follicles; a few open directly onto the skin surface.Their secretion is sebum,a lipid substance that inhibits the growth of some bacteria and prevents drying of skin and hair.D.Modified sweat glands called ceruminous glands are found in the dermis of the ear canals.Their secretion is called cerumen or earwax.A.C.Sweat provides cooling,and melanin is a pigment.

Question 18

The nurse is preparing wet dressings for a patient who has a weeping skin lesion.What is the maximum length of time the wet dressings should be used?

Accepted Answer

Wet dressings should not be prescribed for more than 72 hours,because the skin may become too dry or macerated.A.B.C.Wet dressing can be applied for up to 48 hours.

Question 19

The nurse is reviewing the function and repair of the skin with a patient recovering from burns.Which proteins should the nurse explain as being found in the dermis? (Select all that apply.)

Accepted Answer

Keratinocytes produce the protein keratin.Collagen is the most abundant protein in the body.A.Sebum is a lipid substance.B.Elastin makes the dermis elastic.E.Cerumen is wax.F.Adipose tissue is subcutaneous tissue,not associated with protein.

Question 20

While changing the dressing on a burned arm the patient complains of feeling cold and having extreme pain.However,the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb.What should these findings indicate to the nurse?

Accepted Answer

Sensory receptors for the cutaneous senses reside in the dermis.Receptors for heat,cold,and pain are free nerve endings; encapsulated nerve endings are specific for touch and pressure.The sensitivity of an area of skin is determined by the density of receptors present.A.B.D.These are incorrect interpretations of the patient's response and extent of injury to the nerve endings in the burned arm.

Quiz 53: Integumentary System Function,Assessment,and Therapeutic Measures