Chapter 42: The Integumentary System My Nursing Test Banks

Chapter 42: The Integumentary System

MULTIPLE CHOICE

1. The nurse is aware that the gradual graying of an older adults hair is related to:

a.

reduced hair follicles.

b.

less sebaceous gland activity.

c.

loss of collagen fibers in dermis.

d.

decreased melanocytes at hair follicle.

ANS: D

Reduction in melanocytes at the hair follicle is the cause of graying hair. A reduction in the number of hair follicles will result in thinning hair. Reduced sebaceous gland activity and collagen will result in drying.

DIF: Cognitive Level: Comprehension REF: 953-954 OBJ: 2 (clinical)

TOP: Skin Assessment: Hair KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. An 80-year-old resident prefers to lie in bed on her left side. The nurse will take extra care in assessing the left ______ for evidence of skin breakdown.

a.

buttock

b.

heel

c.

trochanter

d.

ribs

ANS: C

The areas that are prone to break down in the immobile patient are over bony prominences.

DIF: Cognitive Level: Application REF: 960 OBJ: 5 (theory)

TOP: Pressure Ulcer: Risk KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

3. The nurse reminds the CNAs that the main chemical that damages skin of the immobilized patient is:

a.

urine.

b.

medications.

c.

skin lotions.

d.

laundry soap.

ANS: A

Urine and feces are the most common chemical irritants that cause skin breakdown.

DIF: Cognitive Level: Comprehension REF: 961 OBJ: 5 (theory)

TOP: Skin Injury: Chemical KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

4. The action of the CNA that the nurse observes that would be harmful to a patients skin is:

a.

lifting the patient on the draw sheet to the stretcher.

b.

pulling the draw sheet out from under the patient.

c.

rolling the patient to the side to change the draw sheet.

d.

using the gait belt to lift the patient from the bed to a wheelchair.

ANS: B

Pulling linens out from under a patient instead of rolling or lifting the patient causes a shearing type of skin tear. Use of a lift sheet, rolling the patient from side to side, and the use of the gait belt are recommended.

DIF: Cognitive Level: Application REF: 964 OBJ: 5 (theory)

TOP: Skin Injury: Shearing KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

5. When planning care for an 80-year-old African American woman, the nurse would include interventions to:

a.

bathe twice a week.

b.

use liberal amount of soap and water.

c.

use friction while drying patient to stimulate the skin.

d.

apply emollient to limbs and back.

ANS: B

People with dark complexions need to be bathed frequently due to the oiliness of their skin. Liberal amounts of water and soap are beneficial. Friction and application of emollient are not conducive to skin health.

DIF: Cognitive Level: Application REF: 954 OBJ: 4 (theory)

TOP: Bathing: Dark Complexion Considerations

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. A 93-year-old resident eats only a few bites at meals and then refuses to eat more. To help delay skin breakdown from diminished nutrition, the nurse would:

a.

spoon-feed the resident.

b.

request an order for a feeding tube.

c.

inform resident of the need to increase intake.

d.

offer 4 ounces of fluid every hour.

ANS: D

Dehydration can cause loss of skin turgor and predisposes the skin to breakdown. Spoon-feeding and instructing about increased intake may only result in a power struggle with the resident.

DIF: Cognitive Level: Comprehension REF: 955 OBJ: 2 (theory)

TOP: Skin Damage: Dehydration KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

7. The school nurse advises a group of high school girls that to avoid permanent skin damage from sun exposure they should:

a.

use a tanning booth.

b.

use a spray-on tan.

c.

sunbathe on a cloudy day.

d.

wear light, loose clothing while in sun.

ANS: B

A spray-on tan is the safest method to acquire a tan. Booths tan by UV rays. UV rays can penetrate clouds and loose clothing.

DIF: Cognitive Level: Application REF: 955 OBJ: 10 (theory)

TOP: Avoiding Ultraviolet (UV) Skin Damage

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. When applying lotion to the skin, the nurse should:

a.

avoid shaking lotion as this causes bubble formation.

b.

apply lotion heavily as the water from lotion evaporates.

c.

wash off residue before applying fresh lotion.

d.

dab on lotion to reduce skin irritation.

ANS: C

The residue from previous applications should be removed before applying fresh lotion.

DIF: Cognitive Level: Application REF: 963 OBJ: 3 (clinical)

TOP: Lotion: Application KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. The nurse best describes a shave biopsy of a skin lesion as:

a.

removal of the central core of the lesion.

b.

excising the entire lesion with a 1/4-inch border around it.

c.

removal of the top of the lesion that stands above the skin line.

d.

excising the lesion down to the dermis.

ANS: C

The shave biopsy removes the top level of the lesion, which stands above the skin line. Removal of a core from the center of the lesion is referred to as a punch biopsy. Excision of the entire lesion is an excisional biopsy.

DIF: Cognitive Level: Comprehension REF: 957 OBJ: 7 (theory)

TOP: Shave Biopsy: Technique KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. To decrease the threat of a pressure ulcer, the nurse instructs a person who is in a wheelchair for long periods to:

a.

reposition self every 2 hours.

b.

lift weight on the arms of the chair every 15 minutes.

c.

massage bony prominences of the buttocks and hips.

d.

use a donut device to keep weight off of the buttocks.

ANS: B

Lifting or off-loading weight every 15 minutes while in a wheelchair will reduce the threat of pressure ulcer. Tissue anoxia can result in less than 2 hours. Movement to shift weight every 15 minutes is most effective. Massage can damage delicate tissues in the at-risk patient. The donut device reduces circulation to the area compressed and is contraindicated.

DIF: Cognitive Level: Application REF: 956 OBJ: 5 (theory)

TOP: Pressure Ulcer: Prevention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. The nurse assesses that the older adult is not dehydrated when a fold of skin pinched up on the upper chest of the patient returns to normal position in _____ seconds.

a.

6

b.

8

c.

9

d.

10

ANS: A

If the tented skinfold takes more than 8 seconds to return to normal position, the patient is considered to be dehydrated.

DIF: Cognitive Level: Knowledge REF: 960 OBJ: 2 (clinical)

TOP: Test for Dehydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. The nurse teaches the patient the ABCD technique for evaluating melanomas. In this memory prompt, the D stands for:

a.

darkness.

b.

drainage.

c.

dimpling.

d.

diameter.

ANS: D

The D stands for diameter. The A is for asymmetrical, the B is for border, and the C is for color change.

DIF: Cognitive Level: Comprehension REF: 960 OBJ: 1 (clinical)

TOP: ABCD Guide to Melanoma Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

13. The student nurse is preparing to document a suspicious area over a bony prominence. Which description would be most appropriate?

a.

Reddened area on left hip

b.

Reddened, nonblanching area approximately 1 cm 1 cm

c.

Suspicious area over left trochanter

d.

Nonblanching area over left trochanter 0.8 cm 1.2 cm

ANS: D

The area should be described as to location, appearance, and exact measurement.

DIF: Cognitive Level: Application REF: 960 OBJ: 2 (clinical)

TOP: Stage I Pressure Ulcer: Documentation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. A newly admitted 86-year-old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch like crazy. Which is the most likely cause and the best nursing action?

a.

Senile purpura, and employs skin tear precautions

b.

Scabies, and employs Standard Precautions

c.

Senile itch, and employs use of emollient

d.

Allergy, and employs focused assessment for cause

ANS: B

Scabies is treated with Standard Precautions to avoid spread of infestation.

DIF: Cognitive Level: Analysis REF: 958 OBJ: 3 (theory)

TOP: Scabies: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. After a medicated bath, the patient is assisted from the tub and lotion is applied:

a.

immediately after drying the patient.

b.

in a thick layer to warm skin.

c.

when the patient is returned to bed.

d.

by the patient to preserve modesty.

ANS: A

Medication is applied in a thin layer as soon as the patient has completed a bath.

DIF: Cognitive Level: Application REF: 955 OBJ: 3 (clinical)

TOP: Medicated Bath and Lotion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. The nurse is aware that an order for an open dressing requires that:

a.

the lesion is left open to air.

b.

wet compresses are changed frequently enough to keep them wet.

c.

medicated ointment is placed directly in the open wound.

d.

dressings are redampened to keep wet, but not changed.

ANS: B

An open dressing is a wet dressing that is kept that way, but the dressed lesion is not covered with an occlusive dressing as is a closed dressing. The dressing should be changed with each application.

DIF: Cognitive Level: Application REF: 963 OBJ: 3 (clinical)

TOP: Open Dressings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

17. The nurse includes in the discharge teaching of a person with a skin condition that in order to reduce the soap in bed linens and sleeping garments, the patient should:

a.

use fabric softener sheets in the dryer.

b.

use vinegar in the rinse water.

c.

use a fragrant detergent.

d.

send linens to a professional laundry.

ANS: B

The use of vinegar in the rinse water will cut soap that may be irritating to the skin if left in bed linens or sleeping garments.

DIF: Cognitive Level: Comprehension REF: 962 OBJ: 7 (theory)

TOP: Laundry Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

18. The nurse notes that the patient has a 2 1 cm skin tear on the right buttock. The nurse notes a full-thickness skin loss. Which category of skin tears is most consistent with this description?

a.

I

b.

II

c.

III

d.

IV

ANS: C

Category III skin tears have complete tissue loss in which the epidermal flap is missing. Category I skin tears do not have tissue loss. Category II skin tears reflect a partial tissue loss. There is no Category IV.

DIF: Cognitive Level: Comprehension REF: 956 OBJ: 2 (clinical)

TOP: Skin Tears KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The nurse is teaching a group of teenagers about skin care and sun damage. Which statement by a participant indicates the need for further instruction?

a.

Although I have a darker complexion, I am still at risk for sun damage.

b.

The safest time of day to engage in water sports and avoid sun damage is from 10 AMto noon.

c.

My sunscreen should ideally have SPF 30 or higher.

d.

It is important to apply sunscreen about 30 minutes before sun exposure.

ANS: B

The rays of the sun are most damaging between 10 AM and 2 PM standard time. Individuals having darker complexions are still at risk for sun damage. The sunscreen should have a minimum of 30 SPF. The application of sunscreen 15 to 30 minutes before sun exposure is needed.

DIF: Cognitive Level: Application REF: 955 OBJ: 4 (theory)

TOP: Health Promotion: Sun Exposure Precautions

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance

20. The patient reports to the nurse that the physician has ordered a Woods light examination. The nurse correctly recognizes the physician is concerned that the patient may have which condition?

a.

Tinea corpus

b.

Scabies

c.

Herpes simplex

d.

Dermatitis

ANS: A

The Woods light is a specially designed ultraviolet light source. It is helpful in the diagnosis of fungal infections such as tinea corpus.

DIF: Cognitive Level: Application REF: 957 OBJ: 6 (theory)

TOP: Microscopic Tests KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

21. A skin biopsy has been scheduled on a patient to rule out the presence of a malignancy. Which instruction should be provided to the patient?

a.

A general anesthesia will be used during the procedure.

b.

The bandage should be changed the day after the procedure and then weekly for 2 weeks.

c.

The sutures placed at the site of the biopsy will be removed in approximately 10 days.

d.

The patient will need to be NPO 6 to 8 hours before the procedure.

ANS: C

A skin biopsy can be used to rule out a malignancy or to diagnose the causative organism in a lesion. There is no preparation needed. The procedure may be performed under local anesthesia. The bandage will be changed daily. The sutures will be removed in 10 to 14 days after the procedure.

DIF: Cognitive Level: Application REF: 957 OBJ: 6 (theory)

TOP: Diagnostic Tests and Procedures: Skin Biopsy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

22. The nurse lists the age-related changes to the integumentary system, which include: (Select all that apply.)

a.

elastic fibers and adipose tissue diminish.

b.

skin thins and becomes transparent.

c.

hair thins as follicles decrease.

d.

skin becomes dry.

e.

thinned skin leads to intolerance of cold.

ANS: A, B, C, D, E

All options listed are age-related changes seen in the integument.

DIF: Cognitive Level: Knowledge REF: 955 OBJ: 1 (theory)

TOP: Age-Related Changes to Integument

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse advises the older adult to alter bathing practices to include: (Select all that apply.)

a.

using lotion-based soaps.

b.

using hot water to stimulate skin.

c.

strenuous toweling to dry skin.

d.

applying lotion twice a day.

e.

using talcum to dry out skin.

ANS: A, D

Using lotion-based soaps and applying lotion twice a day will help keep the skin moist. All other options increase dryness of skin.

DIF: Cognitive Level: Application REF: 955 OBJ: 2 (theory)

TOP: Older Adult: Bathing KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. The nurse assesses several risk factors for skin tears on the admission of a 90-year-old resident, which include: (Select all that apply.)

a.

incontinence.

b.

bruised areas.

c.

obesity.

d.

prolonged use of corticosteroids.

e.

history of congestive heart disease.

ANS: B, D, E

The elderly have a high risk for the development of skin tears. Risk factors that will further increase the likelihood for developing tears include the presence of bruises, prolonged use of corticosteroids, and systemic conditions such as a history of congestive heart failure. Incontinence and obesity are associated with the incidence of pressure ulcers.

DIF: Cognitive Level: Application REF: 956 OBJ: 2 (theory)

TOP: Skin Tears: Risk Factors in the Elderly

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

25. An 86-year-old resident struck her forearm on a table, causing a category I L-shaped skin tear 6 cm 2 cm. The nurse should: (Select all that apply.)

a.

clean the tear with alcohol.

b.

approximate the edges of the tear.

c.

secure the skin flap with Steri-Strips.

d.

cover with a nonadherent dressing.

e.

assess closely for 5 days for signs of infection.

ANS: B, C, D, E

Alcohol would act as an irritant to the skin tear and should be avoided. Cleansing with normal saline is recommended. The remaining options are appropriate for the management of the skin tear.

DIF: Cognitive Level: Application REF: 956-957 OBJ: 5 (theory)

TOP: Skin Tears: Interventions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

COMPLETION

26. The nurse reminds the junior high school health class that the first line of defense from pathogens for the body is the ____________.

ANS:

skin

The intact skin is the first defense of the body from pathogens.

DIF: Cognitive Level: Knowledge REF: 954 OBJ: 1 (theory)

TOP: Skin: First Line of Defense KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

MATCHING

The nurse uses a picture to show the structure of the integument. Match the options with the characteristic that best describes them. (Each option may be used once, more than once, or not at all.)

a.

Epidermis

b.

Dermis

c.

Sebaceous glands

d.

Sweat glands

27. Squamous epithelium, no blood vessels

28. Contains vessels, nerves, and hair follicles

29. Keeps skin and hair pliable

30. Consists of dense connective tissue

31. Excretes water and salt

27. ANS: A DIF: Cognitive Level: Knowledge REF: 952-953

OBJ: 1 (theory) TOP: Integumentary Structures and Function

KEY: Nursing Process Step: NA MSC: NCLEX: NA

28. ANS: B DIF: Cognitive Level: Knowledge REF: 952-953

OBJ: 1 (theory) TOP: Integumentary Structures and Function

KEY: Nursing Process Step: NA MSC: NCLEX: NA

29. ANS: C DIF: Cognitive Level: Knowledge REF: 952-953

OBJ: 1 (theory) TOP: Integumentary Structures and Function

KEY: Nursing Process Step: NA MSC: NCLEX: NA

30. ANS: B DIF: Cognitive Level: Knowledge REF: 952-953

OBJ: 1 (theory) TOP: Integumentary Structures and Function

KEY: Nursing Process Step: NA MSC: NCLEX: NA

31. ANS: D DIF: Cognitive Level: Knowledge REF: 952-953

OBJ: 1 (theory) TOP: Integumentary Structures and Function

KEY: Nursing Process Step: NA MSC: NCLEX: NA

The nurse clarifies the descriptive terms for skin disorders. Match each option with the characteristic that best describes it.

a.

Erythrasma

b.

Wheal

c.

Fungal infection

d.

Keratosis

e.

Keloid

32. Thick ridge of scar tissue

33. Fluoresces under Woods light

34. Chronic bacterial infection in skinfolds, especially axilla and between toes

35. Smooth, elevated area that is pale or reddened

36. Benign wartlike lesions on trunk, arms, and scalp

32. ANS: E DIF: Cognitive Level: Comprehension REF: 958

OBJ: 2 (clinical) TOP: Skin Lesions: Characteristics KEY: Nursing Process Step: NA

MSC: NCLEX: NA

33. ANS: C DIF: Cognitive Level: Comprehension REF: 957

OBJ: 2 (clinical) TOP: Skin Lesions: Characteristics KEY: Nursing Process Step: NA

MSC: NCLEX: NA

34. ANS: A DIF: Cognitive Level: Comprehension REF: 957

OBJ: 2 (clinical) TOP: Skin Lesions: Characteristics KEY: Nursing Process Step: NA

MSC: NCLEX: NA

35. ANS: B DIF: Cognitive Level: Comprehension REF: 959

OBJ: 2 (clinical) TOP: Skin Lesions: Characteristics KEY: Nursing Process Step: NA

MSC: NCLEX: NA

36. ANS: D DIF: Cognitive Level: Comprehension REF: 958

OBJ: 2 (clinical) TOP: Skin Lesions: Characteristics KEY: Nursing Process Step: NA

MSC: NCLEX: NA

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