Question 1

The nurse is assessing an adolescent patient who presents with acne. When teaching the patient why this occurs, which reason will the nurse provide?

Accepted Answer

Increased sebum production is a primary factor in the development of acne. Sebum, produced by sebaceous glands, can clog pores and lead to acne when overproduced, often influenced by hormonal changes during adolescence.

Question 2

The nurse is assessing a patient's skin and notes jaundice, a yellow discoloration of skin. Which conclusion by the nurse is most appropriate based on this assessment finding?

Accepted Answer

Jaundice, the yellow discoloration of the skin, is most commonly caused by liver impairment. It occurs when there is an accumulation of bilirubin, a yellow pigment that is a byproduct of the breakdown of red blood cells, which the liver normally processes and excretes.

Question 3

A bull's-eye rash may be indicative of which problem?

Accepted Answer

A bull's-eye rash, also known as erythema migrans, is a characteristic sign of Lyme disease, which is caused by the bacterium Borrelia burgdorferi transmitted through tick bites.

Question 4

The nurse is assessing a school-age patient with a skin disorder. Which disorder is most likely to occur during childhood?

Accepted Answer

Varicella, also known as chickenpox, is a common childhood illness characterized by an itchy rash and flu-like symptoms.

Question 5

The nurse is providing care to a patient who presents with a fever. Which is the most appropriate action by the nurse during the assessment process?

Accepted Answer

Assessing vital signs is the most appropriate and initial action when a patient presents with a fever, as it provides critical information about the patient's physiological status, including temperature, heart rate, respiratory rate, and blood pressure.

Question 6

The nurse notes that a pregnant patient is experiencing chloasma on the face. For which reason does the change occur during pregnancy?

Accepted Answer

Chloasma, also known as melasma or the "mask of pregnancy," occurs due to increased estrogen levels during pregnancy, which can stimulate melanocytes to produce more melanin, leading to darkened patches on the skin, particularly on the face.

Question 7

The nurse is assessing a patient who is experiencing a pruritic rash. Which is a cause of this assessment finding?

Accepted Answer

All of the above options (A: Allergic reactions to environmental exposure, B: Medications, C: Renal failure) are potential causes of a pruritic rash, indicating that multiple factors can contribute to this symptom.

Question 8

The nurse is assessing the skin color for a dark-skinned patient. Which location is most appropriate for the nurse to use for this assessment?

Accepted Answer

The oral mucosa is an appropriate location for assessing skin color in dark-skinned patients because it can provide clear indications of color changes that might not be visible on the external skin due to pigmentation.

Question 9

The nurse assessing a patient who is experiencing renal failure. Which change to the integumentary system does the nurse anticipate for this patient?

Accepted Answer

Uremic frost is a condition that can occur in patients with severe renal failure. It is caused by the crystallization of urea on the skin as a result of elevated levels of urea in the blood, which is a consequence of the kidneys' inability to properly eliminate waste products.

Question 10

The nurse is conducting a skin assessment for a patient who has a mole. Which question is most appropriate during this assessment?

Accepted Answer

When assessing a mole, it's important to determine any changes over time, including when it was first noticed. This helps in evaluating the potential for skin cancer or other skin conditions.

Question 11

Which is a primary function of the integumentary system?

Accepted Answer

The primary function of the integumentary system, which includes the skin, hair, nails, and exocrine glands, is to serve as the first line of defense against environmental hazards such as pathogens and physical damage.

Question 12

The nurse is assessing the skin of several patients at the community clinic. Which patient is at the greatest risk for developing skin cancer?

Accepted Answer

Individuals with fair skin, especially those with red hair and of Irish descent, have a higher risk of developing skin cancer due to lower amounts of melanin in their skin. Melanin provides some protection against the damaging effects of UV radiation.

Question 13

The nurse is assessing the skin of an adult patient and notes a wound. The patient states, "I just can't seem to get this sore to heal." Which is the priority assessment question by the nurse?

Accepted Answer

A history of diabetes is crucial to know because diabetes can significantly impair wound healing due to poor circulation and potential neuropathy, making it a priority to assess in a patient with a non-healing wound.

Question 14

Which is the best location for the nurse to assess cyanosis for a dark-skinned patient with congestive heart failure?

Accepted Answer

Cyanosis in dark-skinned patients is best assessed in areas with less pigmentation, such as the buccal mucosa, where changes in color are more easily observed.

Question 15

The nurse is providing care to a patient who is prescribed valproic acid for the treatment of a seizure disorder. Which will the nurse assess for during the skin examination?

Accepted Answer

Valproic acid can cause alopecia (hair loss) as a side effect, which the nurse should assess for during a skin examination.

Question 16

The nurse is assessing a patient with a skin condition. Which condition is the most common during the fall?

Accepted Answer

The answer of The nurse is assessing a patient with...

Question 17

The nurse is providing care to an African American patient. Which is a common skin assessment finding for a patient of this ethnicity?

Accepted Answer

Keloids, which are raised, thickened areas of scar tissue, are more common in individuals of African descent, including African Americans. This is due to differences in wound healing and collagen production.

Question 18

A student nurses asks the nursing instructor why an infant's skin appears reddened. Which response by the nursing instructor is most appropriate?

Accepted Answer

Infants have thinner skin and less subcutaneous fat, which can make their skin appear more reddened due to the visibility of underlying blood vessels.

Question 19

The nurse is providing care to a newborn. Which is a normal assessment finding that often occurs within the first 2 to 3 days of life for this patient?

Accepted Answer

Physiologic jaundice is a common and usually harmless condition in newborns that often appears within the first 2 to 3 days of life. It occurs due to the baby's liver maturing and being able to process bilirubin, a substance produced by the breakdown of red blood cells.

Question 20

The nurse is assessing an adolescent client who is experiencing increased perspiration. Which location will the nurse assess to determine apocrine gland functioning?

Accepted Answer

Apocrine glands are primarily located in areas such as the underarms and groin, and they become active during puberty, contributing to increased perspiration in these areas.

Quiz 2: Assessing the Integumentary System