Deck 2: Assessing the Integumentary System

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?

A) Increased lipid levels
B) Increased sebum production
C) Increased cardiac output
D) Increased hemoglobin production

Answer 1

Increased sebum production

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?

A) Impaired cardiovascular circulation
B) Diminished oxygen concentration
C) Liver impairment
D) Renal impairment

Answer 2

Liver impairment

Question 3

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

A) Herpes zoster
B) Lyme disease
C) Lupus
D) Tinea corporis

Answer 3

Lyme disease

Question 4

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

A) Acne
B) Psoriasis
C) Varicella
D) Rosacea

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?

A) Assess for confusion
B) Assess vital signs
C) Assess for lethargy
D) Assess for irritability

Question 6

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

A) Increased estrogen levels
B) Increased hemoglobin production
C) Decreased testosterone production
D) Fluid retention

Question 7

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

A) Allergic reactions to environmental exposure
B) Medications
C) Renal failure
D) All of the above

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?

A) Sclera
B) Oral mucosa
C) Soles of the feet
D) Abdominal region

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?

A) Jaundice
B) Thinning hair
C) Uremic frost
D) Thickened nails

Question 10

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

A) "Do you have any allergies?"
B) "When did you first notice this?"
C) "Have you noticed any rashes?"
D) "Do you often have a runny nose?"

Question 11

Which is a primary function of the integumentary system?

A) First line of the body's defense
B) Increases body temperature
C) Synthesizes vitamin E
D) Absorbs ultraviolet rays

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?

A) 38-year-old, red-haired female of Irish descent
B) 42-year-old African American male
C) 50-year-old female of Mediterranean descent
D) 52-year-old Hispanic male

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?

A) "How often are you cleaning it?"
B) "Do your clothes rub against the wound?"
C) "Do you have a history of diabetes?"
D) "Do you have any allergies?"

Question 14

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

A) Nail beds
B) Palms
C) Buccal mucosa
D) Conjunctiva

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?

A) Alopecia
B) Pruritic rash
C) Toxic epidermal necrolysis
D) Stevens-Johnson syndrome

Question 16

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

A) Eczema
B) Tinea
C) Urticaria
D) Impetigo

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?

A) Keloids
B) Age spots
C) Increased risk for sunburn
D) Decreased facial hair

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?

A) "The infant's skin color is caused by an excessive breakdown of erythrocytes."
B) "The infant's skin color is caused by increased lipid levels."
C) "The infant's skin color is caused by diminished peripheral circulation."
D) "The infant's skin color is caused by lower amounts of subcutaneous tissue."

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?

A) Decreased elasticity
B) Physiologic jaundice
C) Pronounced body odor
D) Hyperpigmentation of the skin

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?

A) Legs
B) Underarms
C) Chest
D) All of the above

Question 21

Which primary lesion is a flat area of color change, less than 1 cm in size, that is often referred to as a freckle?

A) Macule
B) Patch
C) Papule
D) Plaque

Question 22

The nurse is assessing a patient who presents with a lesion. When distinguishing between a primary lesion and a secondary lesion, which rationale is correct?

A) A secondary lesion results from a change in a primary lesion.
B) A secondary lesion results from injury to the skin.
C) A secondary lesion differs in configuration.
D) A secondary lesion contains exudate.

Question 23

The nurse is assessing a patient who presents with a bruised ankle caused by an injury. When documenting this finding, which term is most appropriate for the nurse to use?

A) Petechiae
B) Ecchymosis
C) Purpura
D) Venous star

Question 24

Which normal skin variation might be noted when assessing an older adult patient's skin?

A) Increased moisture
B) Decreased turgor
C) Increased temperature
D) Decreased texture

Question 25

When inspecting the nails for clubbing, which is the normal angle of attachment?

A) 45 degrees
B) 90 degrees
C) 160 degrees
D) 180 degrees

Question 26

Which is a palpable, serous fluid-filled primary skin lesion that is less than 1 cm in size?

A) Cyst
B) Vesicle
C) Bulla
D) Pustule

Question 27

Which pressure ulcer presents as a full-thickness loss with extensive involvement of supporting structures?

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

Question 28

The nurse is assessing a patient who presents with a pressure ulcer. There is full-thickness loss involving subcutaneous tissue. When documenting this finding, which stage will the nurse use?

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

Question 29

The nurse is assessing the skin of a patient who believes that a new lesion may be melanoma. Which finding would support this patient's concern?

A) Collagen formation
B) Border irregularity or notching
C) Avascularity of the lesion
D) Depth of the color change

Question 30

The nurse notes a pus-filled primary skin lesion. Which term will the nurse use when documenting this finding?

A) Cyst
B) Vesicle
C) Bulla
D) Pustule

Question 31

Which primary skin lesion presents as a temporary elevation of the skin?

A) Macule
B) Keloid
C) Papule
D) Wheal

Question 32

Which is a primary skin lesion that is considered a raised macule?

A) Patch
B) Papule
C) Wheal
D) Nodule

Question 33

Which term will the nurse use when documenting bluish spider veins found during a skin assessment?

A) Capillary hemangioma
B) Spider angioma
C) Telangiectasia
D) Venous star

Question 34

Which term is used to describe scar tissue caused by excessive collagen formation?

A) Fissure
B) Erosion
C) Excoriation
D) Keloid

Question 35

During a skin assessment, the nurse notes an extravasation of blood into the skin layers that was caused by an injury. Which is most appropriate when documenting this finding?

A) Ecchymosis
B) Petechiae
C) Purpura
D) Telangiectasia

Question 36

Which secondary skin lesion is a linear break in the skin with well-defined borders that may extend into the dermis?

A) Fissure
B) Erosion
C) Excoriation
D) Keloid

Question 37

Which vascular lesion is red and blanches with palpation?

A) Venous star
B) Capillary angioma
C) Spider angioma
D) Port-wine stain