Chapter 28: Integumentary Function My Nursing Test Banks

Chapter 28: Integumentary Function

Meiner: Gerontologic Nursing, 5th Edition

MULTIPLE CHOICE

1. The nurse explains that the plan of care for an older adult patient with seborrheic dermatitis of the scalp should include:

a.

cleaning lesions with a weak hydrogen peroxide solution daily.

b.

cleaning the scalp with a low-dose steroidal shampoo.

c.

applying hydrocortisone 10% to scalp lesions.

d.

applying selenium shampoo to the scalp.

ANS: D

A successful strategy is to wet the hair, apply selenium shampoo, and then proceed with the rest of the bath or shower. The other measures will not be successful.

DIF: Remembering (Knowledge) REF: Page 611 OBJ: 28-3

TOP: Teaching-Learning MSC: Physiologic Integrity

2. An older adult patient reports simple xerosis with mild pruritus. The nurse educates her on the importance of:

a.

applying a lanolin-rich cream and avoiding scratching the areas.

b.

taking warm baths and gently rubbing of affected areas with a terrycloth towel.

c.

minimizing ingestion of fried foods and use of an antihistamine cream.

d.

avoiding bath oils and allowing the skin to air-dry after bathing.

ANS: A

The nurse suggests that the patient apply emollients (e.g., Lubriderm, Moisturel, or Eucerin lotion or cream), which have more lanolin or oily substances than many commercial lotions. Time should be planned to teach the patient and family about etiologic factors and the importance of not scratching. The other options are not helpful and will not decrease the itching.

DIF: Understanding (Comprehension) REF: Page 612 OBJ: 28-3

TOP: Teaching-Learning MSC: Health Promotion

3. The nurse plans to assess for candidiasis as a priority intervention for a:

a.

60-year-old with a history of bacterial pneumonia.

b.

72-year-old incontinence of urine and feces.

c.

58-year-old with a casted left foot.

d.

90-year-old receiving antihypertensives.

ANS: B

Candidiasis is most commonly seen in diaper-clad infants, incontinent patients, and bed-bound individuals and in moisture-prone areas of the body (e.g., skin folds and axillae). The other patients are not as likely to have this disorder as the incontinent patient.

DIF: Understanding (Comprehension) REF: Page 612 OBJ: 28-3

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

4. An 87-year-old patient developed herpes zoster after surgical repair of a hip fracture. The priority nursing diagnosis is:

a.

impaired skin integrity related to immunologic deficit.

b.

self-care deficit related to severe pain and fatigue.

c.

risk for infection related to impaired skin integrity.

d.

pain related to inadequate pain relief from analgesia.

ANS: C

These vesicles are extremely vulnerable to secondary bacterial infections. The other diagnoses might be appropriate for some patients.

DIF: Applying (Application) REF: N/A OBJ: 28-3

TOP: Nursing Process: Diagnosis MSC: Physiologic Integrity

5. The presence of which skin assessment finding, if noted on an older adult patient, should cause the nurse to suspect a premalignancy?

a.

Numerous small red papules on the chest and back

b.

An oozing, rough, reddish macule on the ear

c.

An irregularly shaped mole on the face or shoulders

d.

Brown, greasy lesions on the neck

ANS: B

Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. Actinic keratosis may evolve into squamous cell carcinoma (SCC) if not treated, so it should receive prompt attention. Red papules, irregularly shaped moles, and brown greasy lesions are not likely to be precancerous.

DIF: Understanding (Comprehension) REF: Page 615 OBJ: 28-4

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

6. An older adult patient has been taught measures to prevent the development of skin cancer. Which statement, if made by the patient, indicates the need for more teaching?

a.

I will certainly miss my vegetable and flower gardening.

b.

I should buy a sunscreen with an SPF of 15 or higher.

c.

Now I have a good excuse to wear the straw hat my spouse hates.

d.

My cool long-sleeved shirts will work just fine while Im golfing.

ANS: A

The patient is still able to garden as long as he or she takes appropriate sun precautions. The other statements show good understanding.

DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-4

TOP: Nursing Process: Evaluation MSC: Health Promotion

7. When assessing the older adult patients skin for indications of melanoma, the nurse should inspect for a(n):

a.

thick, adherent scale with a soft center.

b.

small, inflamed lesion that bleeds easily.

c.

irregularly shaped multicolored mole.

d.

small, purple, hard nodule beneath the skin surface.

ANS: C

Melanomas clinical hallmark is an irregularly shaped nevus (mole), papule, or plaque that has undergone a change, particularly in color. The other options do not display the characteristic signs.

DIF: Remembering (Knowledge) REF: Page 618 OBJ: 28-4

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

8. An older adult patient newly diagnosed with peripheral vascular disease (PVD) is being educated on the possibility of developing a foot ulcer. What assessment finding indicates the patient may have an ulcer resulting from this disease?

a.

Deep, necrotic, and painless sore

b.

Shiny, dry, cyanotic skin surrounding the ulcer

c.

Ulcer appears shallow, crusty with warm skin

d.

Sore that has dull pain and is oozing

ANS: B

As the disease advances, the extremity develops a cyanotic hue and becomes cool. The skin becomes thin, shiny, and dry and has an associated loss of hair and thickened nails, all of which results from the diminished blood supply. This assessment finding indicates PVD.

DIF: Remembering (Knowledge) REF: Page 619 OBJ: 28-5

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

9. An older adult patient has an open, draining wound on the lower medial aspect of the right leg. The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based on this information, the nurse edits the patients care plan to include impaired skin integrity:

a.

related to altered venous circulation.

b.

peripheral related to arterial insufficiency.

c.

related to diabetic neuropathy.

d.

open wound related to pressure ulcer.

ANS: A

Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is no indication the patient is a diabetic. There is no indication the patient has risks for pressure ulcers.

DIF: Applying (Application) REF: N/A OBJ: 28-5

TOP: Nursing Process: Analysis MSC: Physiologic Integrity

10. When assessing for squamous cell cancer (SCC), a home health nurse is particularly concerned about a suspicious lesion on the:

a.

leg of a 60-year-old Asian female.

b.

neck of a 73-year-old Hispanic female.

c.

Lower lip of a 70-year-old African American male.

d.

back of a 90-year-old Caucasian male.

ANS: C

SCC is skin cancer arising from the epidermis and is found most often on the scalp, outer ears, lower lip, and dorsum of the hands. Approximately 90% of lip lesions can be attributed to squamous cell carcinoma. SCC is more common in men and older adults. SCC is the most common skin cancer in African-Americans.

DIF: Remembering (Knowledge) REF: Page 617 OBJ: 28-4

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

11. A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse educates the patient to the possibility of developing:

a.

alopecia.

b.

orange-tinged urine.

c.

yellow-brown nails.

d.

cherry angiomas.

ANS: C

Changes in the nails occur in approximately 30% of patients and consist of yellow-brown discoloration with pitting, dimpling, separation of the nail plate from the underlying bed (oncolysis), thickening, and crumbling.

DIF: Understanding (Comprehension) REF: Page 610 OBJ: 28-3

TOP: Teaching-Learning MSC: Physiologic Integrity

12. The nurse of a bedridden 74-year-old woman is evaluating whether the family members understand how to position the patient correctly. The nurse is confident the family is capable of effective positioning when it is observed that the patients:

a.

arms and legs are supported on two pillows.

b.

position is changed at least every 2 hours.

c.

neck is hyperflexed.

d.

elbows rest on the bed.

ANS: B

In the 1950s, Kosiak (1958) found that pressure applied to rabbits ears over 2 hours would result in ulceration. Thus, the universal recommendation of turning every 2 hours was established. The other observations do not show the family necessarily understands effective positioning if the patient is not turned.

DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-6

TOP: Nursing Process: Evaluation MSC: Physiologic Integrity

13. An older diabetic patient reports a candidiasis infection. When asked, the patient states all blood sugars have been within the target range. What action by the nurse is best?

a.

Facilitate having a hemoglobin A1c drawn.

b.

Teach the patient preventive measures.

c.

Teach the patient about the side effects of medications.

d.

Review the patients medication history.

ANS: A

Often candidiasis infections in diabetics indicate hyperglycemia. The patient may or may not be truthful about the blood sugar reports, or the patient may be missing periods of hyperglycemia when testing. The nurse should consult with the provider about checking an A1C. The other options are appropriate as well but do not give information as to the background cause.

DIF: Applying (Application) REF: N/A OBJ: 28-3

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

14. An older patient has been treated for a small basal cell carcinoma on the face. What assessment finding indicates to the nurse that the goals for a priority diagnosis have been met?

a.

The patient verbalizes relief there is no metastasis.

b.

Wound edges are approximated without redness.

c.

The patient expresses satisfaction with the cosmetic outcome.

d.

The patient relates the need for proper sun protection.

ANS: B

All findings indicate positive resolution of various nursing diagnoses. However, physical diagnoses take priority, so the best response is the one that indicates lack of infection.

DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-4

TOP: Nursing Process: Evaluation MSC: Physiologic Integrity

15. In creating community education on various types of skin cancer, the nurse places the highest priority on early diagnosis of melanoma because:

a.

it accounts for the largest number of mortalities.

b.

extensive surgery can be avoided if caught early.

c.

once it has spread there is no chance of curing it.

d.

it is the most commonly occurring skin cancer.

ANS: A

Melanoma only accounts for 5% of skin cancer diagnoses but causes 75% of skin cancer mortality. Therefore, it is critical that the condition is diagnosed promptly.

DIF: Remembering (Knowledge) REF: Page 618 OBJ: 28-4

TOP: Teaching-Learning MSC: Health Promotion

16. An older diabetic patient has impaired mobility and decreased vision. The nurse examines the patients feet at each clinical visit. The patient asks why this is necessary. What response by the nurse is best?

a.

Its part of our diabetic clinic visit protocol.

b.

You may not be able to see a sore on your feet.

c.

Limited mobility may keep you from checking your feet.

d.

You may get an ulcer and not be able to feel it.

ANS: D

A diabetic with peripheral neuropathy may not be able to feel injuries on the feet. The injury may progress to a nonhealing ulcer requiring amputation. If the patient had good sensation to the feet, not being able to see or limited mobility would not be as big of a barrier because the patient could report the symptoms. Foot assessment is part of a diabetic clinic protocol.

DIF: Analyzing (Analysis) REF: N/A OBJ: 28-5

TOP: Teaching-Learning MSC: Physiologic Integrity

17. For which patient does the nurse add compression therapy to the nursing care plan?

a.

Taut, white, shiny skin

b.

Faint pedal pulses

c.

Brownish skin and edema

d.

Large ulcer with skin graft

ANS: C

Compression is the mainstay of venous ulcer treatment, and it should be applied when there is brownish skin and edema. The taut white shiny skin and faint pulses indicate arterial insufficiency, and compression will compromise circulation in those extremities even further. A skin graft needs to be protected, as it is vulnerable until healed.

DIF: Analyzing (Analysis) REF: N/A OBJ: 28-5

TOP: Nursing Process: Planning MSC: Physiologic Integrity

18. The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is most important to add to the patients care plan?

a.

Encourage high-protein meals and snacks

b.

Turn the patient every to 2 hours

c.

Assess the patients skin daily

d.

Monitor patients prealbumin weekly

ANS: B

A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most important intervention is to turn the patient frequently. Good nutrition is important for wound healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately impact the patients skin condition. Assessing the skin will not prevent an ulcer.

DIF: Applying (Application) REF: N/A OBJ: 28-7

TOP: Nursing Process: Planning MSC: Physiologic Integrity

19. A patient has a purulent, foul-smelling leg wound. What wound care practice is most appropriate?

a.

Leave the wound open to the air.

b.

Administer systemic antibiotics.

c.

Cleanse the wound with diluted povidone iodine.

d.

Prepare the patient for operative dbridement.

ANS: C

Antiseptics are not used on healthy granulating tissue. Povidone iodine must be diluted and only used short term. A moist environment is needed for healing; leaving the wound open to air will cause too much drying. The patient may eventually need operative dbridement. Systemic antibiotics may or may not be needed.

DIF: Applying (Application) REF: N/A OBJ: 28-10

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

20. A patient has a wound that is a shallow crater with surrounding erythema and warmth. What stage pressure ulcer does the nurse chart?

a.

Stage I

b.

Stage II

c.

Stage III

d.

Stage IV

ANS: B

Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. A stage I pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness deep craters. Stage IV ulcers may extend into the fascia and may be necrotic.

DIF: Remembering (Knowledge) REF: Page 630-1 OBJ: 28-5

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

MULTIPLE RESPONSE

1. The nurse knows that several age-related changes in the integumentary system increase older adults risk for pressure ulcers. Which factors does this include? (Select all that apply.)

a.

Poor nutrition

b.

Living in a nursing home

c.

Thinning epidermis

d.

Decreased skin elasticity

e.

Vessel degeneration

ANS: C, D, E

Thinning epidermis, decreased elasticity of the skin, and deterioration of the vasculature are all age-related changes increasing risk of pressure ulcer development. Poor nutrition and living in a nursing home are not expected age-related changes.

DIF: Remembering (Knowledge) REF: Page 622-4 OBJ: 28-6 | 28-2

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

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