Deck 23: Nursing Assessment: Integumentary System

Question 1

The nurse assesses a circular,flat,reddened lesion about 5 cm in diameter on a middle-aged patient's ankle.How should the nurse determine if the lesion is related to intradermal bleeding?

A) Elevate the patient's leg.
B) Press firmly on the lesion.
C) Check the temperature of the skin around the lesion.
D) Palpate the dorsalis pedis and posterior tibial pulses.

Answer 1

Press firmly on the lesion.

Question 2

When examining an older patient in the home,the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body.Which action should the nurse take first?

A) Discourage the use of throw rugs throughout the house.
B) Ensure the patient has a pair of shoes with non-slip soles.
C) Talk with the patient alone and ask about what caused the bruising.
D) Notify the health care provider so that x-rays can be ordered as soon as possible.

Answer 2

Talk with the patient alone and ask about what caused the bruising.

Question 3

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?

A) Several dry, scaly patches on the face
B) Numerous varicosities noted on both legs
C) Dilation of small blood vessels on the face
D) Petechiae present on the chest and abdomen

Answer 3

Petechiae present on the chest and abdomen

Question 4

When performing a skin assessment,the nurse notes several angiomas on the chest of an older patient.Which action should the nurse take next?

A) Assess the patient for evidence of liver disease.
B) Discuss the adverse effects of sun exposure on the skin.
C) Teach the patient about possible skin changes with aging.
D) Suggest that the patient make an appointment with a dermatologist.

Question 5

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?

A) Reports a history of allergic rashes
B) Scattered macular brown areas on extremities
C) Skin brown and wrinkled, skin tenting on forearm
D) Longitudinal nail bed ridges noted; sparse scalp hair

Question 6

During assessment of the patient's skin,the nurse observes a similar pattern of small,raised lesions on the left and right upper back areas.Which term should the nurse use to document these lesions?

A) Confluent
B) Zosteriform
C) Generalized
D) Symmetric

Question 7

When taking the health history of an older adult,the nurse discovers that the patient has worked in the landscaping business for 40 years.The nurse will plan to teach the patient about how to self-assess for which clinical manifestations ?

A) Vitiligo
B) Alopecia
C) Intertrigo
D) Erythema
E) Actinic keratosis

Question 8

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back.The nurse should prepare the patient for which type of biopsy?

A) Shave biopsy
B) Punch biopsy
C) Incisional biopsy
D) Excisional biopsy

Question 9

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot.Which items should the nurse gather for this procedure?

A) Sterile gloves
B) Patch test instruments
C) Cotton-tipped applicators
D) Local anesthetic, syringe, and intradermal needle

Question 10

A patient reports chronic itching of the ankles and continuously scratches the area.Which assessment finding will the nurse expect?

A) Hypertrophied scars on both ankles
B) Thickening of the skin around the ankles
C) Yellowish-brown skin around both ankles
D) Complete absence of melanin in both ankles

Question 11

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?

A) Administer patch testing to a patient with allergic dermatitis.
B) Interview a new patient about chronic health problems and allergies.
C) Apply a sterile dressing after the health care provider excises a mole.
D) Teach a patient about site care after a punch biopsy of an upper arm lesion.
E) Explain potassium hydroxide testing to a patient with a superficial skin infection.

Question 12

A dark-skinned patient has been admitted to the hospital with chronic heart failure.How would the nurse best assess this patient for cyanosis?

A) Assess the skin color of the earlobes.
B) Apply pressure to the palms of the hands.
C) Check the lips and oral mucous membranes.
D) Examine capillary refill time of the nail beds.

Question 13

A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face.Which additional assessment information will be most important for the nurse to obtain?

A) History of sun exposure by the patient
B) Method of birth control used by the patient
C) Length of time the patient has used fluorouracil
D) Appearance of the treated areas on the patient's face