Deck 23: Nursing Assessment: Integumentary System

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

A) schedule a nursing assistant to help the patient bathe several times weekly.
B) teach the patient to apply a moisturizing body lotion daily.
C) consult with the health care provider to obtain a prescription for a topical antifungal.
D) ask about use of prescription and over-the-counter (OTC) skin medications.

Answer 1

schedule a nursing assistant to help the patient bathe several times weekly.

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.)

A) alopecia.
B) intertrigo.
C) wrinkling.
D) melanoma.
E) telangiectasia.
F) actinic keratosis.

Answer 2

wrinkling.
melanoma.
telangiectasia.
actinic keratosis.

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?

A) "Skin warm and dry; longitudinal nailbed ridges noted, sparse scalp hair."
B) "Skin moist and intact; no skin breakdown noted. History of allergic rashes."
C) "Skin brown, no skin tenting present. States no past or current skin problems."
D) "Skin pink, no open areas noted. Scattered macular brown areas on extremities."

Answer 3

"Skin moist and intact; no skin breakdown noted. History of allergic rashes."

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)

A) shave biopsy.
B) punch biopsy.
C) incisional biopsy.
D) excisional biopsy.

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

A) palpate the dorsalis pedis and posterior tibial pulses.
B) check the temperature of the skin around the lesion.
C) elevate the patient's leg.
D) press firmly on 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

A) discoid and symmetric.
B) annular and grouped.
C) gyrate and diffuse.
D) linear and zosteriform.

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

A) assess for a bluish tinge in the sclera.
B) apply pressure to the palms of the hands.
C) check the lips and oral mucous membranes.
D) examine the nailbeds for capillary refill.

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

A) skin atrophy.
B) keloid formation.
C) lichenification.
D) skin varicosity.

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,

A) "These skin changes are probably associated with malignancy."
B) "You may need to use a more effective moisturizing lotion."
C) "You will need to schedule an appointment with a dermatologist to have these treated."
D) "Angiomas are normal in aging, but they are can be associated with some diseases."

Question 10

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

A) Do you have any pain that you associate with skin problems?
B) What kinds of skin moisturizers and cosmetics do you use?
C) Has the appearance of your skin led to any changes in your social activities?
D) Have you noticed any recent skin changes such as dryness or slow healing?

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?

A) Petechiae present on the chest and abdomen
B) Numerous varicosities noted on both legs
C) Several dry, scaly patches on the face
D) Fingernails have multiple longitudinal ridges

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?

A) Apply moisturizing lotion to the area.
B) Assess the area daily for atrophy.
C) Scrub the affected area vigorously.
D) Cover the area with a sterile dressing.

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?

A) Rupture one of the vesicles and take a specimen from the center of the lesion.
B) Aspirate a specimen from one of the bullae with a sterile 27-gauge needle.
C) Take a specimen by swabbing the infected area with a sterile applicator.
D) Obtain aerobic and anaerobic specimens using the appropriate culture materials.