Deck 17: Integumentary Function

Question 1

The nurse of a bedridden 74-year-old woman is evaluating whether the family members understand how to position the patient correctly.The nurse is confident the family is capable of effective positioning when it is observed that the family members perform which action?

A)Support the arms and legs on two pillows.
B)Turn the patient at least every 2 hours.
C)Hyperflex the neck using pillows
D)Rest elbows on the bed with lower arms elevated.

Answer 1

Turn the patient at least every 2 hours.

Question 2

For which patient does the nurse add compression therapy to the nursing care plan?

A)Taut,white,shiny skin
B)Faint pedal pulses
C)Brownish skin and edema
D)Large ulcer with skin graft

Answer 2

Brownish skin and edema

Question 3

An older adult patient reports pruritus.The nurse educates the patient on the importance of which action?

A)Applying a lanolin-rich cream and avoiding scratching the areas
B)Taking warm baths and gently rubbing of affected areas with a terrycloth towel
C)Minimizing ingestion of fried foods and use of an antihistamine cream
D)Avoiding bath oils and allowing the skin to air-dry after bathing

Answer 3

Applying a lanolin-rich cream and avoiding scratching the areas

Question 4

A patient has a wound that is a shallow lesion with a red,moist wound bed.What stage pressure ulcer does the nurse chart?

A)Stage I
B)Stage II
C)Stage III
D)Stage IV

Question 5

An older diabetic patient has impaired mobility and decreased vision.The nurse examines the patient's feet at each clinical visit.The patient asks why this is necessary.What response by the nurse is best?

A)"It's part of our diabetic clinic visit protocol."
B)"You may not be able to see a sore on your feet."
C)"Limited mobility may keep you from checking your feet.
D)"You may get an ulcer and not be able to feel it."

Question 6

An older patient has been treated for a small basal cell carcinoma on the face.What assessment finding indicates to the nurse that the goals for a priority diagnosis have been met?

A)The patient verbalizes relief there is no metastasis.
B)Wound edges are approximated without redness.
C)The patient expresses satisfaction with the cosmetic outcome.
D)The patient relates the need for proper sun protection.

Question 7

The nurse plans to assess for candidiasis as a priority intervention for which patient?

A)60-year-old with a history of bacterial pneumonia
B)72-year-old incontinence of urine and feces
C)58-year-old with a casted left foot
D)90-year-old receiving antihypertensives

Question 8

An 87-year-old patient developed herpes zoster after surgical repair of a hip fracture.The priority nursing diagnosis is

A)impaired skin integrity related to immunologic deficit.
B)self-care deficit related to severe pain and fatigue.
C)risk for infection related to impaired skin integrity.
D)pain related to inadequate pain relief from analgesia.

Question 9

When assessing for squamous cell cancer (SCC),a home health nurse is particularly concerned about which suspicious lesion?

A)Leg of a 60-year-old Asian female
B)Neck of a 73-year-old Hispanic female
C)Lower lip of a 70-year-old African American male
D)Back of a 90-year-old Caucasian male

Question 10

A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis.The nurse educates the patient to the possibility of developing which other manifestation?

A)Alopecia
B)Orange-tinged urine
C)Yellow-brown nails
D)Cherry angiomas

Question 11

When assessing the older adult patient's skin,what finding would indicate the need to notify the provider as the priority?

A)Thick,adherent scale with a soft center
B)Small,inflamed lesion that bleeds easily
C)Irregularly shaped multicolored mole
D)Small,purple,hard nodule beneath the skin surface

Question 12

The nurse explains that the plan of care for an older adult patient with seborrheic dermatitis of the scalp should include which actions?

A)Cleaning lesions with a weak hydrogen peroxide solution daily
B)Cleaning the scalp with a low-dose steroidal shampoo
C)Applying hydrocortisone 10% to scalp lesions
D)Applying selenium shampoo to the scalp

Question 13

In creating community education on various types of skin cancer,the nurse places the highest priority on early diagnosis of melanoma because

A)it accounts for the largest number of mortalities.
B)extensive surgery can be avoided if caught early.
C)once it has spread there is no chance of curing it.
D)it is the most commonly occurring skin cancer.

Question 14

A patient has a purulent,foul-smelling tunneling leg wound.What wound care practice is most appropriate?

A)Leave the wound open to the air.
B)Administer systemic antibiotics.
C)Pack the wound with iodine-impregnated gauze.
D)Prepare the patient for operative debridement.

Question 15

An older adult patient newly diagnosed with peripheral vascular disease (PVD).What assessment finding indicates the patient may have an arterial ulcer resulting from this disease?

A)Deep,necrotic,and painless sore
B)Shiny,dry,cyanotic skin surrounding the ulcer
C)Ulcer appears shallow,crusty with warm skin
D)Sore that has dull pain and is oozing

Question 16

An older adult patient has an open,draining wound on the lower medial aspect of the right leg.The skin surrounding the wound is reddish brown with surrounding erythema and edema.Based on this information,the nurse edits the patient's care plan to include impaired skin integrity related to which factor?

A)Altered venous circulation
B)Arterial insufficiency
C)Diabetic neuropathy
D)Pressure ulcer

Question 17

An older adult patient has been taught measures to prevent the development of skin cancer.Which statement,if made by the patient,indicates the need for more teaching?

A)"I will certainly miss my vegetable and flower gardening."
B)"I should buy a sunscreen with an SPF of 15 or higher."
C)"Now I have a good excuse to wear the straw hat my spouse hates."
D)"My cool long-sleeved shirts will work just fine while I'm golfing."

Question 18

The nurse assesses a patient using the Braden scale.The patient scores a 13.What action is most important to add to the patient's care plan?

A)Encourage high-protein meals and snacks.
B)Turn the patient every to 2 hours.
C)Assess the patient's skin daily.
D)Monitor patient's prealbumin weekly.

Question 19

The presence of which skin assessment finding should cause the nurse to suspect a premalignancy?

A)Numerous small red papules on the chest and back
B)A rough,reddish macule on the ear
C)An irregularly shaped mole on the shoulders
D)Brown,greasy lesions on the neck

Question 20

An older diabetic patient reports a candidiasis infection.When asked,the patient states all blood sugars have been within the target range.What action by the nurse is best?

A)Facilitate having a hemoglobin A_1C drawn.
B)Teach the patient preventive measures.
C)Teach the patient about the side effects of medications.
D)Review the patient's medication history.

Question 21

The nurse knows that several age-related changes in the integumentary system increase older adults' risk for pressure ulcers.Which factors does this include? (Select all that apply. )

A)Poor nutrition
B)Living in a nursing home
C)Thinning epidermis
D)Decreased skin elasticity
E)Vessel degeneration