Deck 59: Assessment of Integumentary Function

Question 1

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply.

A) Producing antibodies
B) Absorbing electrolytes
C) Maintaining acidbase balance
D) Physically repelling pathogens
E) Preventing fluid loss

Answer 1

Physically repelling pathogens
Preventing fluid loss

Question 2

When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?

A) The scalp
B) The elbows
C) The palms of the hands
D) The knees

Answer 2

The palms of the hands

Question 3

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe
Bruising on the skin in documentation?

A) Telangiectasias
B) Ecchymoses
C) Purpura
D) Urticaria

Answer 3

Ecchymoses

Question 4

The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?

A) Cherry angiomas
B) Solar lentigo
C) Seborrheickeratoses
D) Xanthelasma

Question 5

While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis?

A) Cyanosis
B) Addisons disease
C) Polycythemia
D) Vitiligo

Question 6

While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?

A) Macules
B) Papules
C) Vesicles
D) Pustules

Question 7

An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?

A) Elbows
B) Lips
C) Nail beds
D) Sclerae

Question 8

A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?

A) Is the rash worse at a particular time or season?
B) Are you allergic to any foods or medication?
C) Are you having any loss of sensation in that area?
D) Is your rash painful?

Question 9

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?

A) By avoiding the use of moisturizing lotions on older adults skin
B) By protecting older adults against shearing injuries
C) By avoiding the use of ice packs to treat muscle pain
D) By protecting older adults against excessive sweat accumulation

Question 10

A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient?

A) Ulcer
B) Ecchymosis
C) Scar
D) Erosion

Question 11

A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?

A) Skin scrapings
B) Skin biopsy
C) Patch testing
D) Tzanck smear

Question 12

A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?

A) Tzanck smear
B) Skin biopsy
C) Patch testing
D) Skin scrapings

Question 13

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

A) E
B) D
C) A
D) C

Question 14

A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation?

A) Alopecia
B) Yellowish skin tone
C) Patchy, bronze pigmentation
D) Hirsutism

Question 15

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?

A) An insect bite
B) Dehydration
C) Sunburn
D) Excessive perspiration

Question 16

A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?

A) Crust
B) Keloid
C) Pustule
D) Ulcer

Question 17

An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patients face is a cherry-red color. What should the nurse suspect?

A) Carbon monoxide poisoning
B) Anemia
C) Jaundice
D) Uremia

Question 18

A nurse is providing an educational presentation addressing the topic of Protecting Your Skin. When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin?

A) Islets of Langerhans
B) Squamous cells
C)T cells
D) Melanocytes

Question 19

A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?

A) Dermis
B) Subcutaneous tissue
C) Epidermis
D) Stratum corneum

Question 20

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?

A) Vesicle
B) Macule
C) Nodule
D) Wheal

Question 21

While assessing a 25-year-old female, the nurse notes that the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. The nurse should suspect what type of health problem?

A) A metabolic disorder
B) A malignancy
C) A hormonal imbalance
D) An infectious process

Question 22

An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patients course of treatment?

A) Increased thickness of the subcutaneous skin layer
B) Increased vascular supply to superficial skin layers
C) Changes in the character and quantity of bacterial skin flora
D) Increased time required for wound healing

Question 23

A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves? Select all that apply.

A) Palpation of the patients scalp
B) Palpation of the patients upper extremities
C) Palpation of a rash on the patients trunk
D) Palpation of a lesion on the patients upper back
E) Palpation of the patients fingers

Question 24

A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patients susceptibility to heat loss is related to atrophy of what skin component?

A) Epidermis
B) Merkel cells
C) Dermis
D) Subcutaneous tissue

Question 25

A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?

A) Decreased resistance to ultraviolet radiation
B) Increased vulnerability to infection
C) Diminished protection of tissues and organs
D) Increased risk of skin malignancies

Question 26

An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many spots on her skin. What would be an appropriate response by the nurse?

A) As people age, they normally develop uneven pigmentation in their skin.
B) These spots are called liver spots or age spots.
C) Older skin is more apt to break down and tear, causing sores.
D) These are usually the result of nutritional deficits earlier in life.

Question 27

An older adult patient is diagnosed with a vitamin $\mathrm{D}$ deficiency. What would be an appropriate recommendation by the nurse?

A) Spend time outdoors at least twice per week
B) Increase intake of leafy green vegetables
C) Start taking a multivitamin each morning
D) Eat red meat at least once per week

Question 28

The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?

A) Is anyone in your family allergic to anything?
B) How long have you had this abrasion?
C) Do you take any over-the-counter drugs or herbal preparations?
D) What do you do for a living?

Question 29

A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?

A) Does anyone in your family have eczema or psoriasis?
B) Have any of your family members been diagnosed with malignant melanoma?
C) Do you have a family history of vitiligo or port-wine stains?
D) Does any member of your family have a history of keloid scarring?

Question 30

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?

A) Has she eaten any new foods today?
B) Has she bathed in the past 24 hours?
C) Did she go to a friends house today?
D) Was she digging in the dirt today?

Question 31

A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?

A) Obtain a swab for culture.
B) Assess the characteristics of the lesion.
C) Obtain a swab for $\mathrm{pH}$ testing.
D) Apply a test dose of broad-spectrum topical antibiotic.

Question 32

The nurse is performing a comprehensive assessment of a patients skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?

A) By examining the patient under a Woods light
B) By inspecting the patients skin in direct sunlight
C) By palpating the patients skin
D) By performing percussion of major skin surfaces

Question 33

A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patients health history, the nurse should identify what comorbidity as increasing the patients vulnerability to skin infections?

A) Chronic obstructive pulmonary disease
B) Rheumatoid arthritis
C) Gout
D) Diabetes

Question 34

A patient with human immunodeficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what?

A) A reduction in the patients CD4 count
B) A reduction in the patients viral load
C) An adverse effect of antiretroviral therapy
D) Virus-induced changes in allergy status

Question 35

Assessment of a patients leg reveals the presence of a $1.5-\mathrm{cm}$ circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?

A) Keloid
B) Ulcer
C) Fissure
D) Erosion

Question 36

A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patients fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?

A) Eczema
B) Systemic lupus erythematosus (SLE)
C) Psoriasis
D) Chronic obstructive pulmonary disease (COPD)

Question 37

A patients health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?

A) Chronic Pain
B) Impaired Skin Integrity
C) Impaired Tissue Integrity
D) Disturbed Body Image

Question 38

A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?

A) Weak positive
B) Moderately positive
C) Strong positive
D) Severely positive

Question 39

A dermatologist has asked the nurse to assist with examination of a patients skin using a Woods light. This test will allow the physician to assess for which of the following?

A) The presence of minute regions of keloid scarring
B) Unusual patterns of pigmentation on the patients skin
C) Vascular lesions that are not visible to the naked eye
D) The presence of parasites on the epidermis

Question 40

A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?

A) Skin biopsy
B) Patch test
C) Tzanck smear
D) Examination with a Woods light