Question 1

When examining an 87-year-old home health patient, the nurse notes a musky, sour body odor. Based on this assessment, the most appropriate nursing action is to

Accepted Answer

The skin odor indicates that the patient's hygiene is poor and that assistance with bathing is needed. Although elderly patients may need moisturizing lotions and should be asked about use of skin medications, the assessment data do not indicate that these are the most appropriate actions. An antifungal would be indicated if the nurse noticed a yeast odor.

Question 2

When taking the health history for a patient, the nurse discovers that the patient works as a roofer. The nurse will plan to teach the patient about how to self-assess for clinical manifestations of (Select all that apply.)

Accepted Answer

A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, melanoma, telangiectasia, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.

Question 3

Which assessment information documented in a patient's chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old patient admitted with bacterial pneumonia?

Accepted Answer

Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other response would be normal for an elderly patient.

Question 4

A patient in the dermatology clinic is scheduled for removal of a 10-mm, multicolored, irregular mole from the upper back. The nurse will plan to teach the patient about a (an)

Accepted Answer

An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant; a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

Question 5

A patient has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. To determine whether the lesion is related to blood vessel dilation, the nurse will

Accepted Answer

If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.

Question 6

During assessment of the patient's skin, the nurse observes a ring of small, raised, blister-like lesions filled with serous fluid on the patient's right temple. The nurse should document the configuration and distribution of these lesions as

Accepted Answer

The description of the lesions is consistent with the terms annular and grouped. The other terminology would describe lesions with a different appearance.

Question 7

A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine whether the patient is cyanotic, the nurse will

Accepted Answer

Inspection of the skin in dark-skinned individuals is easier in areas where the epidermis is thin and the skin is not exposed to the sun. Assessment of the sclera is not useful in checking for cyanosis. Application of pressure to the palms of the hands and nailbed assessment would check for adequate circulation, but not for skin color.

Question 8

A patient reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for

Accepted Answer

Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.

Question 9

A 73-year-old asks the nurse to inspect some large reddened lumps that have recently appeared on the legs. The nurse recognizes the lesions as angiomas and tells the patient,

Accepted Answer

Angiomas are a frequent occurrence as patients age, but they might be an indication of systemic problems such as liver disease. They are not commonly associated with malignancy. Moisturizer use will not impact the appearance or occurrence of angiomas. There is no indication that the patient needs referral to a dermatologist.

Question 10

When obtaining a health history related to the skin, which question will assess the patient's health perception-health maintenance pattern?

Accepted Answer

Included in the health perception-health maintenance pattern are self-care habits such as moisturizer and cosmetic use. Information about pain would be included in the

Question 11

The nurse notes all these changes in the skin of a 95-year-old patient who is being admitted to an assisted-living facility. Which change will be of most concern to the nurse?

Accepted Answer

Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

Question 12

When reading the admission assessment for a patient, the nurse notes that the patient has an excoriated area on the skin of the right forearm. Which nursing action will be included in the plan of care?

Accepted Answer

Excoriated areas should be covered with a dressing to decrease the risk for infection. Application of moisturizer would not help the excoriation and might lead to infection. There is no evidence that the skin is atrophied. Scrubbing the excoriated area would cause further damage.

Question 13

The nurse is preparing to send a culture for a patient who has a possible herpes zoster infection on the chest. Which action is appropriate?

Accepted Answer

For lesions with vesicles or bullae, the lesion should be opened using sterile technique and a specimen obtained from the center of the lesion. Aspiration of bullae would present a risk of injury to the patient. Swabbing the area would be likely to result in obtaining normal skin flora rather than the infectious agent. Anaerobic cultures would be unnecessary for an infection on the skin of the chest and would unnecessarily increase the cost of the culture.

Quiz 23: Nursing Assessment: Integumentary System