Question 1

Which of the following is the best example of nursing documentation of a normal assessment of the skin?&#10;A) &#34;Skin warm and dry;turgor good;nails flat and pink;old surgical scars noted on abdomen.&#34;&#10;B) &#34;History of allergic rashes;skin very fair with numerous freckles,warm and intact;no lesions noted.&#34;&#10;C) &#34;Skin brown,slightly moist,and warm;turgor immediate return;no lesions noted.States no problems with skin.&#34;&#10;D) &#34;No history of skin problems;skin intact,pink;temperature consistent over body;no lesions except numerous brown moles.&#34;

Accepted Answer

This documentation provides a clear description of the skin assessment, including the color, moisture, temperature, turgor, and absence of lesions. It also includes a statement from the patient about their skin. This type of thorough documentation is important for accurately monitoring the patient's skin health and detecting any changes or issues over time.

Question 2

How would the nurse describe vitiligo,a common assessment abnormality of the integumentary system?&#10;A) Tumour consisting of lymph vessels&#10;B) Male-pattern distribution of hair in women&#10;C) Complete absence of melanin resulting in chalky white patches&#10;D) A sac containing fluid or semisolid material

Accepted Answer

Vitiligo is a condition where there is a loss of pigmentation in certain areas of the skin, resulting in chalky white patches.

Question 3

When obtaining a self-care integument history,the nurse will ask the patient about which of the following?&#10;A) Pain associated with skin conditions&#10;B) The brands of moisturizers and cosmetics used&#10;C) Lifestyle changes associated with skin conditions&#10;D) Changes in the condition of the skin,hair,and nails

Accepted Answer

Asking about the brands of moisturizers and cosmetics used is relevant to self-care practices related to the integumentary system.

Question 4

A 73-year-old patient tells the nurse that she is concerned because she has been experiencing large,reddened lumps on her legs for the last 6 to 8 months.The nurse recognizes the lesions as angiomas.Which following response should the nurse give the patient?

A) "Don't worry.These lesions are a normal part of aging."
B) "Angiomas are serious tumours,and you should see your physician about them."
C) "They are probably just related to varicose veins,which are common in older adults."
D) "Have your doctor evaluate them.Although they can be normal in aging,they are also associated with some diseases."

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Accepted Answer

Although angiomas can be a normal part of aging, they can also be associated with some diseases. It is best for the patient to have them evaluated by a physician to rule out any potential underlying issues. Option A is incorrect as it implies the lesions are always normal. Option B is incorrect as angiomas are usually benign and not considered serious tumors. Option C is incorrect as angiomas are not always related to varicose veins.

Question 5

A dark-skinned patient has been admitted to the hospital in severe respiratory distress.What knowledge does the nurse use to assess for cyanosis in the patient?&#10;A) Cyanosis in patients with dark skin can be seen only in the sclera.&#10;B) Cyanosis is not possible to assess in patients with dark skin.&#10;C) Cyanosis can be seen in the conjunctiva of the eye and mucous membranes of patients with dark skin.&#10;D) Cyanosis will blanch out with direct pressure to the soles of the feet in dark-skinned patients.

Accepted Answer

Cyanosis can be observed in the mucous membranes and conjunctiva in dark-skinned patients. Other assessments, such as nail beds, lips, and tongue, may not be as reliable. However, it is important to note that cyanosis is not always present in respiratory distress and may not be the only indicator of compromised respiratory function.

Question 6

Which of the following is an age-related change in the integumentary system?&#10;A) Increased proliferative capacity in the skin&#10;B) Decreased keratin in the nails&#10;C) Decreased melanin in the hair&#10;D) Increased extracellular water in the skin

Accepted Answer

One of the age-related changes in the integumentary system is a decrease in melanin production, which may result in gray or white hair.

Answer: B 
 Another age-related change is a decrease in keratin production, which may result in brittle and weaker nails.

Option A is incorrect because with age, there is a decreased proliferative capacity in the skin. Option D is also incorrect because increased extracellular water in the skin occurs due to certain medical conditions or injuries, not age-related changes.

Question 7

Where would you find apocrine sweat glands?&#10;A) Scalp&#10;B) Eyelids&#10;C) Back&#10;D) Upper chest

Accepted Answer

Apocrine sweat glands are primarily found in areas abundant in hair follicles, such as the armpits, groin, and around the nipples, but they are also present in the eyelids.

Question 8

How would the nurse document a papule?&#10;A) Firm,edematous,irregularly shaped area&#10;B) Elevated,solid lesion smaller than 1 cm in diameter&#10;C) Circumscribed,flat area with a change in skin colour,less than 1 cm in diameter&#10;D) Circumscribed,elevated solid lesion,larger than 1 cm in diameter

Accepted Answer

A papule is defined as an elevated, solid lesion smaller than 1 cm in diameter. It can be described as a palpable, raised area.

Question 9

A patient has an injury to the end of the finger,which has caused the loss of the nail.The nurse informs the patient that the nail can be expected to grow back if permanent damage has not occurred to which of the following parts?

A) Cuticle
B) Nail bed
C) Nail root
D) Nail body

Accepted Answer

The nail root is responsible for nail growth. If it is not permanently damaged, the nail can regrow.

Question 10

What is the primary function of the skin?&#10;A) Sensory perception&#10;B) Mirroring of emotions&#10;C) Protecting underlying tissues of the body&#10;D) Displaying the individual identity of the person

Accepted Answer

The primary function of the skin is to protect the underlying tissues of the body from physical, chemical, and biological damage. It acts as a barrier against harmful environmental factors like UV radiation, pathogens, and toxins, and also helps regulate body temperature and prevent dehydration. While the skin does play a role in sensory perception, mirroring emotions, and displaying individual identity through features like hair and pigmentation, these are secondary functions.

Question 11

When examining a patient,the nurse notes a musky body odour and relates this finding to activity of which of the following glands?&#10;A) Melanocyte glands&#10;B) Ductless glands&#10;C) Apocrine glands&#10;D) Sebaceous glands

Accepted Answer

The answer of When examining a patient,the nurse notes a...

Question 12

A patient has a circular,flat,reddened lesion about 5 cm in diameter on his ankle.How does the nurse know that the lesion is related to vessel dilation?&#10;A) The lesion is painless.&#10;B) The lesion is warmer than the surrounding skin.&#10;C) The discoloration disappears when the leg is elevated.&#10;D) The discoloration blanches temporarily with direct pressure.

Accepted Answer

The answer of A patient has a circular,flat,reddened lesion about...

Question 13

A patient with pruritus has a large area of superficial excavation of the skin on the right forearm.How should the nurse record this finding?&#10;A) Erythema&#10;B) Excoriation&#10;C) Carotenosis&#10;D) Lichenification

Accepted Answer

The answer of A patient with pruritus has a large...

Deck 25: Nursing Assessment: Integumentary System