Deck 58: Nursing Assessment of the Patient With Integumentary Disorders

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?

A) "My skin is so thin and gets injured so easily."
B) "My skin is so greasy even though I wash frequently."
C) "My nails are growing more slowly."
D) "I've had mostly gray hair since I was in my thirties."

Answer 1

"My skin is so greasy even though I wash frequently."

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?

A) Whether clubbing of the nail is present
B) How brittle the nails are
C) Whether the nail is well attached to the nail bed
D) Capillary refill

Answer 2

Capillary refill

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.

A) Merkel's cells
B) Langerhans' cells
C) Dermal dendrocytes
D) Keratinocytes
E) Melanocytes

Answer 3

Langerhans' cells
Dermal dendrocytes
Keratinocytes

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?

A) "Do you have any pets that live inside your house?"
B) "Has anyone in your family ever had skin cancer?"
C) "Have you recently experienced dehydration?"
D) "Have you ever had a cold sore or herpes infection on your lip?"

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?

A) Is the lesion scaly?
B) Is the lesion raised?
C) Does the lesion blanch?
D) Is the lesion painful?

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.

Question 7

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

A) Inspect the skin while the patient is standing up.
B) Be aware of ethnic differences.
C) Examine the least-exposed areas first.
D) Examine only the areas of specific concern.

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?

A) Vitamin D deficiency
B) Hypokalemia
C) Hypernatremia
D) Hypercholesterolemia

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?

A) The cause of the wounds is unimportant.
B) This may be a cultural practice.
C) The patient belongs to a cult.
D) The patient is delusional.

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?

A) The nurse palpates the skin with the dorsal surface of the hand.
B) The nurse palpates the skin with the palmar surface of the fingers and finger pads.
C) The nurse places the palm of the hand on the patient's skin.
D) The nurse touches the skin with the anterior surface of the wrist.

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?

A) Pitting edema
B) Loss of skin elasticity
C) Increased skin turgor
D) Reduced sensation

Question 12

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

A) "My rash first started a week ago."
B) "I have a rash on my arm."
C) "I put some ointment on this rash, but it did not help."
D) "My son had a similar rash last month."

Question 13

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

A) Palpate the skin.
B) Grasp a fold of the patient's skin between the forefinger and thumb.
C) Determine the patient's fluid intake for past 2 hours.
D) Blanch the nail bed.

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?

A) Dietary intake
B) History of hepatitis
C) Food allergies
D) History of hyperlipidemia

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.

A) "How long has it been since you ate strawberries?"
B) "What happens when you eat strawberries?"
C) "What treatments do you use to treat this allergic reaction?"
D) "When was your last allergic reaction?"
E) "Are you allergic to any other foods?"

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?

A) Excoriation
B) Ulceration
C) Lichenification
D) Ecchymosis

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?

A) It reflects the patient's level of education.
B) The patient has had possible exposure to environmental toxins.
C) Patients who work out of doors are more likely to develop skin cancer.
D) The patient probably also uses tobacco.

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?

A) It likely indicates a nutritional deficiency.
B) This is a common finding in dark-skinned individuals.
C) Additional areas should be assessed for cyanosis.
D) The patient has a fungal infection of the nail bed.

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.

A) Peripheral arterial insufficiency
B) Hypothyroidism
C) Overuse
D) Infection
E) Differences in ambient room temperature

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?

A) Cherry angiomas
B) Venous stars
C) Purpura
D) Spider angiomas

Question 21

A patient with dark skin has been admitted for treatment of anemia. The nurse would plan which physical assessments for pallor in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Assess for areas of vitiligo.
B) Look for an ashen appearance.
C) Inspect the palpebral conjunctiva.
D) Assess the color of the earlobes.
E) Inspect the sclera.

Question 22

The nurse assesses several spider angiomas across the chest and lower abdomen of a 60-year-old patient. The patient reports that these lesions have developed within the last several months. Which nursing statement is indicated?

A) "We should check your blood glucose."
B) "Do you take any vitamin supplements?"
C) "These commonly occur with aging."
D) "We should check you for a bladder infection."

Question 23

A patient's skin lesion has been described as a nodule. The nurse expects which findings to be present? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The margins of the lesion are clearly identifiable.
B) The lesion is pus-filled.
C) The lesion is flat and nonpalpable.
D) The lesion is firm.
E) The lesion is within the dermis.

Question 24

The nurse is assessing for changes in the nails of a patient with chronic obstructive pulmonary disease. The nurse would document clubbing of the fingers if the angle of the nail bed exceeds _________ degrees.

Question 25

A patient has been diagnosed with a fungal infection in the intertriginous areas of the toes. The nurse would assess which area for this infection?

A) The area between the toes
B) The distal end of the toes
C) The base of the toenails
D) The underside of the toes

Question 26

A patient presents to the urgent care clinic for treatment of an upper respiratory virus. During assessment, the nurse notes lesions the patient says are caused by "skin popping." How should the nurse respond to this discovery? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) "You really shouldn't do this to yourself."
B) "Skin popping increases your risk for staph infection."
C) "When did you have your last tetanus immunization?"
D) "Don't you know this is not legal?"
E) "Skin popping is probably the way you got the flu."

Question 27

The nurse assesses the presence of linea nigra on the abdomen of a pregnant patient. Which information should the nurse provide about this finding?

A) "You should use a good emollient lotion to help prevent more of these lines."
B) "These lines are caused by the stretching of the skin."
C) "This line will probably go away after your baby is delivered."
D) "We will monitor this lesion for possible removal after you deliver your baby."

Question 28

A patient has a surgical scar that extends beyond the original incision site. The area is raised and smooth, and the patient reports that it occasionally itches but is not tender. How would the nurse document this lesion?

A) Cicatrix
B) Hypertrophic scar
C) Fissure
D) Keloid

Question 29

The nurse would interpret which patient findings as increasing the risk for development of skin cancer? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient is 58 years old.
B) The patient has blonde hair.
C) The patient has an olive complexion.
D) The patient is female.
E) The patient has blue eyes.

Question 30

Review of a patient's medical record reveals the presence of a rash consisting of discrete arciform lesions. The nurse would anticipate that the patient's rash has which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The rash is localized.
B) The rash consists of individual lesions.
C) The rash forms a line across the body.
D) The individual lesions are arc-shaped.
E) The lesions arch across the body.