Chapter 23: Nursing Assessment: Integumentary System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 23: Nursing Assessment: Integumentary System

Test Bank

MULTIPLE CHOICE

1. When the nurse is assessing a 42-year-old woman, the patient states that she is using topical fluorouracil (Efudex, Fluoroplex) to treat actinic keratoses on her face. Which additional information will be most important for the nurse to obtain?

a.

Method of birth control the patient is using

b.

History of extensive sun exposure by the patient

c.

Length of time the patient has used the medication

d.

Appearance of the treated areas on the patients face

ANS: A

Since fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information also will be obtained by the nurse, but lack of reliable birth control has the most potential for serious adverse medication effects.

DIF: Cognitive Level: Application REF: 441

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. Which assessment information documented in a patients 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.

Scattered macular brown areas on extremities

b.

Skin brown and wrinkled, skin tenting on forearm

c.

Longitudinal nail bed ridges noted, sparse scalp hair

d.

Skin moist and intact; states history of allergic rashes

ANS: D

Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other response would be normal for an elderly patient.

DIF: Cognitive Level: Application REF: 438-439

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. 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.

elevate the patients leg.

b.

press firmly on the lesion.

c.

check the temperature of the skin around the lesion.

d.

palpate the dorsalis pedis and posterior tibial pulses.

ANS: B

If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.

DIF: Cognitive Level: Application REF: 443

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. When examining a homebound patient, the home health nurse notes a musky, sour body odor. Based on this assessment, the most appropriate nursing action is to

a.

teach the patient to apply a moisturizing body lotion daily.

b.

ask about use of over-the-counter (OTC) skin medications.

c.

ask the health care provider about a prescription for a topical antifungal.

d.

schedule nursing assistive personnel to help with bathing several times weekly.

ANS: D

The skin odor indicates that the patients hygiene is poor and that assistance with bathing is needed. Although elderly patients may need moisturizing lotions and should be asked about use of skin medications, the assessment data do not indicate that these are the most appropriate actions. An antifungal would be indicated if the nurse noticed a yeast odor.

DIF: Cognitive Level: Application REF: 438 | 443

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

5. 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 the skin color of the earlobes.

b.

apply pressure to the palms of the hands.

c.

check the lips and oral mucous membranes.

d.

examine capillary refill time of the nail beds.

ANS: C

Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation, but not for skin color.

DIF: Cognitive Level: Application REF: 442

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse is preparing to obtain a culture from a patient who has a possible fungal infection in the groin area. Which action is appropriate?

a.

Apply a topical anesthetic before obtaining the culture.

b.

Use sterile gloves to squeeze the lesion and obtain exudate.

c.

Swab the infected area with a sterile cotton-tipped applicator.

d.

Scrape the area gently with a razor blade to obtain a specimen.

ANS: C

Fungal cultures are obtained by swabbing the affected area of the skin. The other actions might be used for obtaining other types of specimens.

DIF: Cognitive Level: Application REF: 446

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. The nurse notes several angiomas on the legs of a 73-year-old patient. Which action should the nurse take next?

a.

Assess the patient for evidence of liver disease.

b.

Discuss the adverse effects of sun exposure on the skin.

c.

Educate the patient about possible skin changes with aging.

d.

Suggest that the patient make an appointment with a dermatologist.

ANS: A

Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.

DIF: Cognitive Level: Application REF: 444

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

8. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse will plan to teach the patient about

a.

shave biopsy.

b.

punch biopsy.

c.

incisional biopsy.

d.

excisional biopsy.

ANS: C

An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant; a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

DIF: Cognitive Level: Application REF: 446 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. During assessment of the patients skin, the nurse observes a ring of small, raised, discrete lesions filled with serous fluid on the patients right temple. When documenting the lesions, the nurse will describe the lesions as

a.

grouped.

b.

confluent.

c.

zosteriform.

d.

generalized.

ANS: A

The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions.

DIF: Cognitive Level: Comprehension REF: 443

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. 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.

lichenification.

c.

skin varicosity.

d.

keloid formation.

ANS: B

Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.

DIF: Cognitive Level: Comprehension REF: 444

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. The nurse notes these abnormalities on the skin of a 95-year-old patient who is being admitted to an assisted living facility. Which abnormality is the priority to discuss immediately with the health care provider?

a.

Several dry, scaly patches on the face

b.

Numerous varicosities noted on both legs

c.

Dilation of small blood vessels on the face

d.

Petechiae present on the chest and abdomen

ANS: D

Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patients health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

DIF: Cognitive Level: Application REF: 444

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. 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.

erythema.

e.

actinic keratosis.

ANS: C, D, E

A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.

DIF: Cognitive Level: Analysis REF: 438 | 444

OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Leave a Reply