Chapter 12: Skin, Hair, and Nails My Nursing Test Banks

Chapter 12: Skin, Hair, and Nails

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

a.

Highly vascular.

b.

Thick and tough.

c.

Thin and nonstratified.

d.

Replaced every 4 weeks.

ANS: D

The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 199

MSC: Client Needs: General

2. The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:

a.

Contains mostly fat cells.

b.

Consists mostly of keratin.

c.

Is replaced every 4 weeks.

d.

Contains sensory receptors.

ANS: D

The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 200

MSC: Client Needs: General

3. The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesnt have an odor. The nurse knows that this condition could be related to:

a.

Eccrine glands.

b.

Apocrine glands.

c.

Disorder of the stratum corneum.

d.

Disorder of the stratum germinativum.

ANS: A

The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patients statement is not related to disorders of the stratum corneum or the stratum germinativum.

DIF: Cognitive Level: Applying (Application) REF: p. 200

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

4. A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?

a.

Subcutaneous fat deposits are high in the newborn.

b.

Sebaceous glands are overproductive in the newborn.

c.

The newborns skin is more permeable than that of the adult.

d.

The amount of vernix caseosa dramatically rises in the newborn.

ANS: C

The newborns skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

DIF: Cognitive Level: Applying (Application) REF: p. 201

MSC: Client Needs: Health Promotion and Maintenance

5. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

a.

Increased vascularity of the skin

b.

Increased numbers of sweat and sebaceous glands

c.

An increase in elastin and a decrease in subcutaneous fat

d.

An increased loss of elastin and a decrease in subcutaneous fat

ANS: D

An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

DIF: Cognitive Level: Applying (Application) REF: p. 201

MSC: Client Needs: Health Promotion and Maintenance

6. During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

a.

Metrocytes.

b.

Fungacytes.

c.

Phagocytes.

d.

Melanocytes.

ANS: D

In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 201

MSC: Client Needs: Health Promotion and Maintenance

7. During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

a.

Xerosis.

b.

Pruritus.

c.

Alopecia.

d.

Seborrhea.

ANS: A

Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 203

MSC: Client Needs: Health Promotion and Maintenance

8. A 22-year-old woman comes to the clinic because of severe sunburn and states, I was out in the sun for just a couple of minutes. The nurse begins a medication review with her, paying special attention to which medication class?

a.

Nonsteroidal antiinflammatory drugs for pain

b.

Tetracyclines for acne

c.

Proton pump inhibitors for heartburn

d.

Thyroid replacement hormone for hypothyroidism

ANS: B

Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

DIF: Cognitive Level: Applying (Application) REF: p. 204

MSC: Client Needs: Health Promotion and Maintenance

9. A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?

a.

Increased possibility of bruising

b.

Skin sensitivity as a result of exposure to salt water

c.

Lack of availability of glucose-monitoring supplies

d.

Importance of sunscreen and avoiding direct sunlight

ANS: D

Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

DIF: Cognitive Level: Applying (Application) REF: p. 204

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

10. A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:

a.

Is contagious.

b.

Has no known cause.

c.

Is caused by increased sebum production.

d.

Has been found to be related to poor hygiene.

ANS: C

Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 205

MSC: Client Needs: Health Promotion and Maintenance

11. A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:

a.

The woman could be at increased risk for infection and lesions because of her chronic disease.

b.

With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding.

c.

She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors.

d.

With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: A

A personal history of diabetes and peripheral vascular disease increases a persons risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

DIF: Cognitive Level: Applying (Application) REF: p. 206

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

12. The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a persons:

a.

Support systems.

b.

Circulatory status.

c.

Socioeconomic status.

d.

Psychological wellness.

ANS: B

The skin holds information about the bodys circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 210

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:

a.

Venous pooling.

b.

Peripheral vasodilation.

c.

Peripheral vasoconstriction.

d.

Decreased arterial perfusion.

ANS: C

A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 12-1).

DIF: Cognitive Level: Applying (Application) REF: p. 207

MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

14. A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:

a.

Pallor

b.

Coolness

c.

Distended veins

d.

Prolonged capillary filling time

ANS: C

Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 12-1).

DIF: Cognitive Level: Applying (Application) REF: p. 207

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

15. A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:

a.

Caused by an excess of melanin pigment

b.

Caused by an excess of apocrine glands in her feet

c.

Caused by the complete absence of melanin pigment

d.

Related to impetigo and can be treated with an ointment

ANS: C

Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orificesotherwise, the depigmented skin is normal.

DIF: Cognitive Level: Applying (Application) REF: p. 207

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

16. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

a.

Color variation

b.

Border regularity

c.

Symmetry of lesions

d.

Diameter of less than 6 mm

ANS: A

Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 208

MSC: Client Needs: Health Promotion and Maintenance

17. A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:

a.

Decreased amounts of bilirubin in the blood

b.

Excess blood in the underlying blood vessels

c.

Decreased perfusion to the surrounding tissues

d.

Excess blood in the dilated superficial capillaries

ANS: D

Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

DIF: Cognitive Level: Applying (Application) REF: p. 209

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

18. During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patients scleras are not yellow. From this finding, the nurse could probably rule out:

a.

Pallor

b.

Jaundice

c.

Cyanosis

d.

Iron deficiency

ANS: B

Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 209

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

19. A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patients skin?

a.

Ruddy blue.

b.

Generalized pallor.

c.

Ashen, gray, or dull.

d.

Patchy areas of pallor.

ANS: C

Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).

DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 208-209

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

20. An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?

a.

Smooth mucous membranes and lips

b.

Dry mucous membranes and cracked lips

c.

Pale mucous membranes

d.

White patches on the mucous membranes

ANS: B

With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

DIF: Cognitive Level: Applying (Application) REF: p. 210

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

21. A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:

a.

Anasarca.

b.

Scleroderma.

c.

Senile angiomas.

d.

Latent myeloma.

ANS: C

Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

DIF: Cognitive Level: Applying (Application) REF: p. 211

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

22. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?

a.

Anasarca

b.

Scleroderma

c.

Pedal erythema

d.

Clubbing of the nails

ANS: D

Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 213

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

23. A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infants mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:

a.

Caf au lait.

b.

Carotenemia.

c.

Acrocyanosis.

d.

Cutis marmorata.

ANS: D

Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A caf au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 217

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

24. A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:

a.

Keratoses.

b.

Xerosis.

c.

Chloasma.

d.

Acrochordons.

ANS: C

In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 220

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

25. A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction?

a.

Senile lentigines, which do not become cancerous

b.

Actinic keratoses, which are precursors to basal cell carcinoma

c.

Acrochordons, which are precursors to squamous cell carcinoma

d.

Seborrheic keratoses, which do not become cancerous

ANS: D

Seborrheic keratoses appear like dark, greasy, stuck-on lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 221

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

26. A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, What causes these liver spots? The nurse tells her, They are:

a.

Signs of decreased hematocrit related to anemia.

b.

Due to the destruction of melanin in your skin from exposure to the sun.

c.

Clusters of melanocytes that appear after extensive sun exposure.

d.

Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.

ANS: C

Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 220

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

27. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:

a.

Bulla.

b.

Wheal.

c.

Nodule.

d.

Papule.

ANS: D

A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 229

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

28. The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

a.

Lesions that run together.

b.

Annular lesions that have grown together.

c.

Lesions arranged in a line along a nerve route.

d.

Lesions that are grouped or clustered together.

ANS: A

Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 227

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

29. A patient has had a terrible itch for several months that he has been continuously scratching. On examination, the nurse might expect to find:

a.

A keloid.

b.

A fissure.

c.

Keratosis.

d.

Lichenification.

ANS: D

Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 232

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

30. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, The physician is referring to the:

a.

Blue dilation of blood vessels in a star-shaped linear pattern on the legs.

b.

Fiery red, star-shaped marking on the cheek that has a solid circular center.

c.

Confluent and extensive patch of petechiae and ecchymoses on the feet.

d.

Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color.

ANS: C

Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 238

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

31. A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:

a.

Eczema.

b.

Impetigo.

c.

Herpes zoster.

d.

Diaper dermatitis.

ANS: B

Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

DIF: Cognitive Level: Applying (Application) REF: p. 239

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

32. The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?

a.

Pink, papular rash on the face and neck

b.

Pruritic vesicles over her trunk and neck

c.

Hyperpigmentation on the chest, abdomen, and back of the arms

d.

Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D

With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 240

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

33. The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:

a.

Measles (rubeola).

b.

Kaposis sarcoma.

c.

Angiomas.

d.

Herpes zoster.

ANS: B

Kaposis sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patients temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.

DIF: Cognitive Level: Applying (Application) REF: p. 244

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

34. A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:

a.

Tinea capitis.

b.

Folliculitis.

c.

Toxic alopecia.

d.

Seborrheic dermatitis.

ANS: A

Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 245

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

35. A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:

a.

Folliculitis that can be treated with an antibiotic.

b.

Traumatic alopecia that can be treated with antifungal medications.

c.

Tinea capitis that is highly contagious and needs immediate attention.

d.

Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

ANS: D

Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

DIF: Cognitive Level: Applying (Application) REF: p. 246

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

36. The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

a.

Severe obesity

b.

Childhood growth spurts

c.

Severe dehydration

d.

Connective tissue disorders such as scleroderma

ANS: C

Decreased skin turgor is associated with severe dehydration or extreme weight loss.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 211

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

37. While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?

a.

Heart failure

b.

Venous thrombosis

c.

Local inflammation

d.

Blockage of lymphatic drainage

ANS: A

Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 210

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

38. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

a.

Tell the patient to watch the lesion and report back in 2 months.

b.

Refer the patient because of the suggestion of melanoma on the basis of her symptoms.

c.

Ask additional questions regarding environmental irritants that may have caused this condition.

d.

Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

ANS: B

The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 208

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

39. The nurse is assessing for clubbing of the fingernails and expects to find:

a.

Nail bases that are firm and slightly tender.

b.

Curved nails with a convex profile and ridges across the nails.

c.

Nail bases that feel spongy with an angle of the nail base of 150 degrees.

d.

Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

ANS: D

The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 213

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

40. The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?

a.

Yellow patches in the outer sclera

b.

Yellow color of the sclera that extends up to the iris

c.

Skin that appears yellow when examined under low light

d.

Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B

The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 209

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

41. The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?

a.

Assessing the skin for cyanosis and swelling

b.

Assessing the oral mucosa for generalized erythema

c.

Palpating the skin for edema and increased warmth

d.

Palpating for tenderness and local areas of ecchymosis

ANS: C

Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

DIF: Cognitive Level: Applying (Application) REF: p. 209

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

42. A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bulls eye pattern across his midriff and behind his knees. The nurse suspects:

a.

Rubeola.

b.

Lyme disease.

c.

Allergy to mosquito bites.

d.

Rocky Mountain spotted fever.

ANS: B

Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bulls eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 242

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

43. A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?

a.

Acne

b.

Basal cell carcinoma

c.

Melanoma

d.

Squamous cell carcinoma

ANS: B

Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

DIF: Cognitive Level: Applying (Application) REF: p. 243

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

44. A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infants:

a.

Sternum.

b.

Forehead.

c.

Forearms.

d.

Abdomen.

ANS: D

Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 218

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

45. A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:

a.

Polycythemia.

b.

Carbon monoxide poisoning.

c.

Carotenemia.

d.

Uremia.

ANS: B

A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 226

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

46. A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patients fingernails?

a.

Splinter hemorrhages

b.

Paronychia

c.

Pitting

d.

Beau lines

ANS: C

Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

DIF: Cognitive Level: Applying (Application) REF: p. 249

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply.

a.

Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color

b.

Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)

c.

Papule: Hypertrophic scar

d.

Vesicle: Known as a friction blister

e.

Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

ANS: A, D, E

A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 229 |p. 238

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

2. A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.

a.

Intact skin appears red but is not broken.

b.

Partial thickness skin erosion is observed with a loss of epidermis or dermis.

c.

Ulcer extends into the subcutaneous tissue.

d.

Localized redness in light skin will blanch with fingertip pressure.

e.

Open blister areas have a red-pink wound bed.

f.

Patches of eschar cover parts of the wound.

ANS: B, E

Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

DIF: Cognitive Level: Applying (Application) REF: p. 233

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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