Deck 53: Integumentary System Function, Assessment, and Therapeutic Measures

Question 1

The nurse is preparing to assist the HCP in obtaining a full-thickness skin biopsy. Which information from the nurse is most appropriate?

A)Explain that the surface of the biopsy area will be shaved off.
B)Inform the patient that a thick area of skin will be punched out.
C)Tell the patient that the most pain will be in numbing the area.
D)Instruct the patient to expect considerable bleeding to occur.

Answer 1

Tell the patient that the most pain will be in numbing the area.

Question 2

A patient has an open skin lesion and the HCP wants the area covered with a dressing after application of an antibiotic ointment. The patient asks the nurse the purpose of covering the area. Which reason does the nurse provide?

A)The dressing is solely for the purpose of retaining moisture.
B)The dressing will prevent the evaporation of the medication.
C)The dressing will reduce pain in the lesion and prevent itching.
D)The dressing will enhance the absorption of the topical medication.

Answer 2

The dressing will enhance the absorption of the topical medication.

Question 3

The nurse is preparing to reexamine the skin of a patient who has a history of malignant skin growths. Which preparation by the nurse is incorrect?

A)Allow the patient to leave on underwear and socks.
B)Plan to use the techniques of inspection and palpation.
C)Include the hair, nails, scalp, and mucous membranes.
D)Explain the need for a penlight and magnifying glass.

Answer 3

Allow the patient to leave on underwear and socks.

Question 4

The nurse is assisting with a skin examination for a patient. The patient asks, "I love the sun, why is everyone so concerned about sun exposure?" Which answer by the nurse is best?

A)"Sun exposure will cause the skin to age and wrinkle."
B)"The sun gives off ultraviolet (UV) rays that destroy vitamin D."
C)"Melanin pigment is a barrier against UV exposure."
D)"UV rays are mutagenic and can cause skin cancers."

Question 5

The nurse is collecting data on an older adult patient with a generalized rash. The patient reports severe itching and the nurse notes open lesions from scratching. Which additional finding causes the nurse the least concern?

A)The patient has uncut fingernails.
B)The patient is wearing soft-soled slippers.
C)The patient has thin hair with seborrhea.
D)The patient has an odor of urine and feces.

Question 6

A patient with widely distributed chronic eczema is prescribed to receive medicated tar baths. Which important detail does the nurse acknowledge during this procedure?

A)The patient will need to be kept in the bath for 1 hour.
B)Old medications will need to be removed prior to the bath.
C)The room needs to have good ventilation because of volatility.
D)Slow addition of hot water will keep the bath temperature stable.

Question 7

The nurse is providing care for a patient with a large skin abrasion to the outer thigh. The HCP has ordered a daily dressing change without disturbance of the healing crusts that have formed in the area. Which dressing material will the nurse select?

A)Gauze 4 * 4s with paper tape to seal the edges of the dressing.
B)A nonadherent dressing for cover and gauze for wrapping.
C)Thick abdominal pad for protection with an elastic wrap.
D)A thin dressing wrapped around the thigh and taped securely.

Question 8

The nurse is caring for a patient in a wound clinic who is treated with plastic wrap dressings. Which findings indicate complications related to prolonged application of the dressings? (Select all that apply.)

A)Cyanosis
B)Folliculitis
C)Maceration
D)Skin atrophy
E)Lichenification

Question 9

A patient presents with skin lesions that appear reddened, with seeping areas partially crusted over. The HCP orders a viral culture to be performed. Which action by the nurse is inappropriate when collecting the culture specimen?

A)An intact vesicle is gently squeezed to obtain fluid.
B)A sterile cotton swab is used to acquire culture material.
C)The collected fluid is evenly distributed over a glass slide.
D)The specimen is immediately transported to the laboratory.

Question 10

The nurse works in an extended-care facility and is assisting in the development of a policy and procedure addressing foot care of the residents. Which intervention does the nurse identify as needing to be reconsidered in regard to routine foot care?

A)Soak the residents' feet briefly in warm water and wash with gentle soap.
B)Use gauze or pads to reduce pressure where toes lie across each other.
C)Use a pumice stone to remove dry skin from heels or callused areas.
D)Apply an alcohol-free lotion to massage and perform range of motion (ROM) on feet and ankles.

Question 11

While changing the dressing on a burned arm, the patient informs the nurse of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. Which conclusion does the nurse draw from the patient's statements?

A)All nerves in the limb are damaged.
B)Free nerve endings in the arm are injured.
C)Encapsulated nerve endings in the arm are intact.
D)Encapsulated nerve endings in the arm are injured.

Question 12

The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding causes the nurse the most concern?

A)Edema formation
B)Dry, macerated skin
C)Increased lesion oozing
D)Excessive skin oiliness

Question 13

The nurse is assisting with the presentation about skin for a group of senior citizens in a community center. Which normal changes associated with aging does the nurse include? (Select all that apply.)

A)Fibroblasts in dermis die.
B)Subcutaneous fat increases.
C)Epidermal cell division slows.
D)Hair follicles become inactive.
E)Sweat glands become more active.

Question 14

The nurse works in an office with a dermatologist. When preparing to assist with a patch test for a client with suspected allergic contact dermatitis, which nursing action is unnecessary?

A)Cleanse the patient's upper back and arms with alcohol.
B)Instruct the patient to keep areas dry and free from moisture.
C)Place resuscitation equipment in the vicinity of the testing.
D)Arrange for the final reading of the testing in 2 to 5 days.

Question 15

The nurse is providing care for a patient diagnosed with a fungal infection in the skinfolds beneath the breasts. The HCP has prescribed the application of an antifungal powder to the affected areas. For which reason does the nurse contact the RN for validation of the prescribed treatment?

A)The area of treatment has developed open sores.
B)The patient has an allergy to cornstarch.
C)The breasts are heavy and pendulant.
D)The patient has a chronic respiratory disease.

Question 16

The nurse in a health care provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

A)Detection of skin cancer early can improve chances of a cure.
B)The skin is a good communicator regarding the patient's health.
C)Skin lesions are seen as solid predictors of general health state.
D)The patient's psychological health is best predicted by the skin.

Question 17

The nurse is assisting with a patient who has a suspected diagnosis of tinea capitis (ringworm). For which diagnostic test does the nurse prepare the patient?

A)Patch test
B)Scratch test
C)Skin biopsy
D)Wood's light examination

Question 18

A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes. For which part of the prescription does the nurse consult with the registered nurse (RN)?

A)Treatment is to continue for 7 days.
B)The procedure is performed with clean technique.
C)Room temperature normal saline is prescribed.
D)The appearance of the area is to be documented.

Question 19

The nurse is assisting in the care of a patient presenting with painful psoriatic lesions. The HCP is preparing for intralesional therapy using a sterile suspension of corticosteroid. Which side effect does the nurse recognize as a possibility with this therapy?

A)Thinning of the skin at the site of the injection
B)Infection from invasive administration of medication
C)Local atrophy if the injection is in subcutaneous tissue
D)Interference with healing if an infection occurs

Question 20

The nurse is assisting in the care of a patient with second-degree burns to the arm. The blisters are not intact. The HCP prescribes an antibiotic ointment to be applied to the open areas twice daily. Which method will the nurse use for applying the prescribed medication?

A)A soft bristle brush
B)A cotton tipped swab
C)A wooden tongue depressor
D)A small surgical sponge