Deck 15: Assessing the Integumentary System

Question 1

When conducting a physical examination of the skin, hair, and nails, the nurse notes the age of the patient. Why is this information important to the nurse?

A) It alerts the nurse to expect age-related changes.
B) It validates that skin changes in the older population are pathologic.
C) It reminds the nurse that scaly, dry skin is more common in young adults.
D) It reinforces the concept that age is the most significant risk factor for cancer.

Answer 1

It alerts the nurse to expect age-related changes.

Question 2

During an integumentary assessment, an older patient is found to have a brown benign macule with a defined border. How should the nurse document this finding?

A) keratosis
B) angioma
C) lentigine
D) a telangiectases

Answer 2

lentigine

Question 3

A patient being seen for an elevated, darkened area of excess scar tissue asks the nurse what caused it. How should the nurse respond?

A) "This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow depression."
B) "This scar was caused by excessive collagen formation during healing."
C) "This scar was caused by skin loss extending into the dermis or subcutaneous tissue."
D) "This scar was caused by wasting of the skin due to loss of collagen."

Answer 3

"This scar was caused by excessive collagen formation during healing."

Question 4

A patient is seen for an erythematous generalized rash. Which questions should the nurse ask regarding the rash?

A) "Have you recently eaten any new foods?"
B) "What medications do you take?"
C) "Have you changed your soap?"
D) "Have you changed skin care lotions?"
E) "How often do you walk outside?"

Question 5

A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will heal and be as it was prior to the burn. What knowledge of skin structures should the nurse use to respond to this patient?

A) Most hair follicles are in the dermis.
B) Most sweat glands are in the dermis.
C) Hair follicles are located in the subcutaneous tissue.
D) Sebaceous glands are located in the dermis.
E) Receptors for pain and touch are located in the dermis.

Question 6

A patient complains of the sudden appearance of white patches on the skin. The nurse, suspecting vitiligo, should ask the patient which questions?

A) "Have any of your parents or grandparents had this problem also?"
B) "Have you been using bleach lately?"
C) "Have you had anything rubbing on those areas excessively?"
D) "What have you been eating lately?"
E) "Where are the white patches located on your body?"

Question 7

While conducting a patient's health history, the nurse learns that the patient has worked at a landfill for the last 35 years. Why should the nurse find this information significant?

A) Explains possible exposure to environmental toxins
B) Helps understand the patient's lack of communication skills
C) Validates that the patient is an older adult
D) Confirms the patient's level of education

Question 8

The nurse is assessing the integumentary status of an older patient. What change should the nurse expect in this patient?

A) a decrease in abdominal fat
B) an increase in perfusion
C) a decrease in vitamin D production
D) an increase in vasomotor response

Question 9

A Caucasian patient is admitted with possible carbon monoxide poisoning. What skin color can the nurse expect to find that would support this diagnosis?

A) bluish
B) dusky red
C) cherry red
D) orange green

Question 10

The nurse is providing care to patients in a community clinic. When should the nurse conduct a health assessment interview to determine problems with the integumentary system?

A) when the patient has a complaint
B) as part of regular health screening
C) when completing a health assessment
D) rarely, because it takes too much time
E) when the patient is over the age of 50

Question 11

The nurse is completing an integumentary examination with an African American patient. Which findings should the nurse recognize are associated with the patient's genetics?

A) an ashen hue to black skin
B) a yellowish cast on the palms
C) very dry scalp and dry, fragile hair
D) several keloids
E) patches of white spots on the hands

Question 12

The nurse is caring for an older patient. What should the nurse keep in mind when caring for the patient's skin?

A) The subcutaneous layer grows thinner.
B) The epidermis thickens.
C) The number of Langerhans cells increases.
D) Sweat gland activity increases.

Question 13

A patient is experiencing a problem with the eccrine sweat glands. Because of this structural problem, the nurse realizes that which function will be affected in this patient?

A) regulation of body temperature
B) regulation of body heat by excretion of perspiration
C) sebum secretion
D) sexual scent gland

Question 14

The nurse is performing an assessment of a patient's nails. What should be included in this examination?

A) nail thickness
B) nail color
C) nail curvature
D) nail length
E) for grooves

Question 15

The nurse is caring for a patient diagnosed with oculocutaneous albinism. What does the nurse understand this health problem to be?

A) hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin
B) disorder characterized by elevated scars and a familial tendency that is found more commonly in African Americans
C) sudden appearance of white patches on the skin, with a familial tendency
D) autosomal-dominant inheritance disorder that causes hyperpigmentation of the skin, hair, and eyes

Question 16

A patient has an area of rough, thickened, hardened epidermis. What should the nurse suspect as the reason for this skin lesion?

A) chronic dermatitis
B) athlete's foot
C) ear piercing
D) psoriasis

Question 17

The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. What is the best way of assessing skin color changes in this patient?

A) Assess the sclera.
B) Assess the palms of the hands.
C) Assess the fingernails.
D) Assess the skin of the inner arms.

Question 18

The nurse is caring for an African American patient who has an ashen cast to his normally black skin. Which laboratory test results should the nurse review to determine a possible cause of the skin color change?

A) BUN
B) hemoglobin and hematocrit
C) bilirubin
D) oxygen saturation

Question 19

During a conversation with the nurse, a patient comments that he rarely goes outside when the sun is shining because he is afraid of developing skin cancer. Which health problem is this patient at risk for developing?

A) vitamin D deficiency
B) hypercholesterolemia
C) hypokalemia
D) hypernatremia

Question 20

A female patient who is concerned about excessive hair on her arms and legs states that her mother had the same problem. How should the nurse respond?

A) "The excessive hair growth could be a result of your diet."
B) "Your hair growth patterns may be inherited."
C) "Your excessive hair growth could be caused by too much sun."
D) "Maybe you shave too much, which causes more hair growth."

Question 21

A patient waiting to have a skin biopsy asks what occurs during the procedure. What should the nurse respond to this patient?

A) "Didn't your doctor tell you?"
B) "Maybe you shouldn't have it done."
C) "I'm not sure."
D) "Let me check to see exactly what you are having done and then we can talk more about what you can expect."

Question 22

The nurse is preparing to assess a patient's integumentary status. Which techniques should the nurse use to conduct this assessment?

A) inspection
B) inspection and percussion
C) inspection and palpation
D) percussion and palpation

Question 23

The nurse is caring for a patient with thinning of the nails. Which test result should the nurse use to aid in the diagnosis of this nail disorder?

A) pulse oximetry
B) hemoglobin
C) serum albumin
D) white blood cell count

Question 24

An adolescent patient has extensive acne over the face and upper neck. The nurse recognizes that this condition is caused by which factor?

A) inflamed sebaceous glands
B) blocked endocrine glands
C) blocked exocrine glands
D) inflamed ceruminous glands

Question 25

The nurse is assessing a patient with the following laboratory values: sodium 144 mEq/L; potassium 3.8 mEq/L; hemoglobin 8.4 g/dL; glucose 105 mg/dL. Which assessment might correlate with these findings?

A) The nail plate is separate from the nail bed.
B) The nail folds are inflamed and swollen.
C) The nail is spoon-shaped.
D) The nail has a transverse groove.

Question 26

The nurse is assessing the integumentary status of a 79-year-old female. Which findings should the nurse considered common in older adults?

A) keratoses
B) skin tags
C) urticaria
D) photoaging
E) acne

Question 27

The nurse is planning to assess an African American patient's integumentary status. Which finding indicates the presence of cyanosis in this patient?

A) yellow hue in the eyes
B) bluish-tinged nail beds
C) cherry-red lips
D) orange-green cast to the skin

Question 28

The nurse is assessing a patient's skin. For what is the nurse assessing when using the technique shown in this picture?

A) hydration status
B) skin temperature
C) skin color
D) liver function

Question 29

A patient diagnosed with heart failure has 3+ lower extremity edema. Which description most accurately describes this patient's edema?

A) slight pitting, no obvious distortion
B) deeper pit, no obvious distortion
C) pit is obvious, extremities are swollen
D) pit remains with obvious distortion

Question 30

The nurse is assessing a patient for nail clubbing. Place an "X" on the area of the fingernail that the nurse should examine.

Question 31

A patient has a history of paronychia. Place an "X" on the area of the fingernail that becomes inflamed in paronychia.

Question 32

Place an "X" over the structure whose decreased activity in older patients causes dry skin or absence of perspiration.

Question 33

After completing an integumentary status assessment, the nurse documents "+1 edema right lower leg." What does this documentation indicate?

A) slight pitting, no obvious distortion
B) deep pitting, no obvious distortion
C) pitting is obvious, extremities are swollen
D) pitting remains with obvious distortion

Question 34

The nurse documents that a patient has 4+ pitting edema on the lower right tibia. How many millimeters of depression did this patient demonstrate?

A) 2 mm
B) 4 mm
C) 6 mm
D) 8 mm

Question 35

The nurse is preparing to conduct the health history of a new clinic patient. The intake notes reveal that the patient has albinism. What assessment finding should the nurse expect in this patient?

A) excessive body hair
B) white patches on the skin
C) overgrowth of scar tissue
D) very pale skin

Question 36

The nurse notes the presence of this lesion on the patient's anterior chest. How should the nurse document this finding in the medical record?

A) purpura
B) ecchymosis
C) venous star
D) spider angioma

Question 37

The nurse has assessed a flat, nonpalpable change in the skin color on a patient's back. What characteristic identifies this skin color change as a macule?

A) smaller than 1 cm, with a circumscribed border
B) larger than 1 cm with an irregular border
C) smaller than 0.5 cm
D) group of lesions larger than 0.5 cm.

Question 38

The nurse notes this distribution of lesions on a patient's skin. Based on this finding, the nurse should perform additional assessment looking for indications of which problem?

A) vitamin B deficiency
B) increased intravenous pressure
C) bleeding disorders
D) psoriasis

Question 39

The patient states, "This dark spot on my arm is getting bigger, and it bleeds occasionally." Which health information is most important relative to this report?

A) The patient's father had chronic obstructive pulmonary disease.
B) The patient plays golf three or four times a week.
C) The patient is male.
D) There is a history of cardiac disease in the patient's family.
E) The patient is a blue-eyed blonde.

Question 40

The nurse is caring for a patient with a skin fissure. Place an "X" over the diagram that represents a skin fissure.

Question 41

During an integumentary assessment the nurse observes multiple areas of ecchymosis over the patient's arms, legs, and upper back. What problems should the nurse consider as causes of these manifestations?

A) Septicemia
B) Hemophilia
C) Liver disease
D) Vitamin C deficiency
E) Vitamin K deficiency

Question 42

A patient is seen in the clinic after having a biopsy that sampled a small section of dermis and subcutaneous fat. For which type of biopsy should the nurse plan care for this patient?

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

Question 43

The nurse is preparing to assess a patient's integumentary status. What should the nurse do prior to beginning this examination?

A) Obtain a gown and drape for the patient
B) Cleanse the blood pressure cuff with alcohol
C) Obtain several pairs of disposable gloves
D) Ensure the examination room is warm and private
E) Place a ruler and flashlight near the examination table

Question 44

The nurse is planning to document the appearance of herpetic lesions found over a patient's nose and mouth region. Which term should the nurse use to describe this finding?

A) scaly
B) pustular
C) pruritic
D) ulcerated

Question 45

Prior to assessing a patient's integumentary status, the nurse notes excessive perspiration. What possible causes should the nurse consider for this finding?

A) The patient is hungry.
B) The patient is anxious.
C) The patient is in shock.
D) The patient has a fever.
E) The patient has been exercising.

Question 46

During the assessment of an older patient's integumentary status, the nurse notes small areas of hyperpigmentation on the patient's hands. What should the nurse consider as the cause of this finding?

A) hyperplasia of melanocytes in sun-exposed areas
B) reduced vitamin D production
C) decreased blood perfusion of the dermis
D) redistribution of adipose tissue

Question 47

The nurse is caring for an older patient with thin subcutaneous tissue. What actions should the nurse take to ensure the patient's comfort and safety?

A) Apply warm blankets
B) Keep the room cool
C) Use a lift sheet to reposition in bed
D) Assess skin for areas of breakdown
E) Encourage frequent position changes

Question 48

The nurse suspects that a school-age child has ringworm of the scalp. What did the nurse assess to come to this conclusion?

A) Coarse, dry hair
B) Areas of hair loss
C) Scaling on the scalp
D) Pustules on the scalp
E) Oval nits on the hair shaft

Question 49

A patient is scheduled for a test to diagnose for the presence of a herpes infection. For which diagnostic test should the nurse prepare the patient?

A) patch test
B) Tzanck smear
C) potassium chloride test
D) Wood's lamp examination