Chapter 44Assessment of Integumentary Function My Nursing Test Banks

Chapter 44Assessment of Integumentary Function

MULTIPLE CHOICE

1.A client has sustained an injury to the skin that extends into the innermost layer, which is called the:

1.

stratum germinativum.

2.

stratum granulosum.

3.

stratum lucidum.

4.

stratum spinosum.

ANS: 1

The epidermis is composed of five layers of stratified squamous epithelial cells named (outer to inner): the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum germinativum.

PTS: 1 REF: Epidermis

2.A client has a yellow tone to the skin. The nurse realizes that which of the following cells are responsible for the yellow tone of the skin?

1.

Carotenoids

2.

Langerhans cells

3.

Melanocytes

4.

Merkel cells

ANS: 1

Carotenoids are responsible for the yellow tone of the skin in some individuals. Langerhans cells are responsible for foreign antigen recognition, and they provide immune protection. Melanocytes are responsible for skin pigmentation. Merkel cells are thought to be involved in sensing touch and pressure.

PTS: 1 DIF: Analyze REF: Cells in the Epidermis

3.A client has a health condition that affects her ability to sweat. The nurse realizes that the sweat glands are epidermal appendages known as:

1.

apocrine glands.

2.

eccrine glands.

3.

hydriatric glands.

4.

sebaceous glands.

ANS: 2

The eccrine glands are sweat-producing glands that play a role in thermoregulation. The apocrine glands produce odorless and milky secretions. Sebaceous glands produce sebum, which functions as a waterproofing layer. Hydriatric is a term meaning treatment with water.

PTS: 1 DIF: Analyze REF: Table 44-1 Structures and Functions of the Skin

4.A client sustained an injury to the crescent-shaped area at the proximal end of the nail of one finger or the:

1.

lunula.

2.

nail matrix.

3.

paronychia.

4.

periungual tissue

ANS: 1

The lunula is the pale, crescent-shaped area at the proximal end of each nail. The periungual tissue surrounds the nail plate and the free edge of the nail. Paronychia is inflammation at the base of the nail plate. The nail matrix is undifferentiated epithelial tissue from which the nails arise.

PTS: 1 DIF: Analyze REF: Epidermal Appendages

5.The nurse is assessing the skin of an elderly client. Which of the following would not be assessed in this client?

1.

Decreased elasticity

2.

Increased skin hydration

3.

Slow wound healing

4.

Thinning skin

ANS: 2

As a person ages, there is a reduction in the density of sweat glands, sebaceous glands, and blood vessels, which results in a decrease in skin hydration. As a person ages, skin loses elasticity. Reduced blood vessels lead to slower wound healing. Reduction in subcutaneous tissue causes the skin to thin.

PTS: 1 DIF: Analyze REF: Cellular Effects of Aging on the Skin

6.A client is experiencing elevated fluid-filled lesions on the skin. The nurse would document these lesions as being:

1.

macules.

2.

nodules.

3.

vesicles.

4.

wheals.

ANS: 3

Vesicles are elevated, fluid-containing lesions. Macules are flat, circumscribed changes of the skin. Nodules are elevated, solid lesions. Wheals are solid elevations formed by local, superficial, transient edema, usually in response to a pruritic condition.

PTS: 1 DIF: Analyze REF: Box 44-1 Primary Lesions

7.A client is experiencing a change in skin status. During the assessment, the nurse asks about any changes in laundry products as part of which of the following systems review?

1.

Environmental changes

2.

Nutritional patterns

3.

Activities and exercise patterns

4.

Cultural influences

ANS: 1

When assessing environmental changes during the assessment of the skin, the nurse would assess for any changes in laundry products. Nutritional patterns would be assessed by changes in diet or food supplements. Activities and exercise patterns would be assessed by any use of protective skin preparations. Cultural influences would be assessed by factors that may influence the choice of treatment options.

PTS:1DIF:Apply

REF: Table 44-2 Review of Systems Related to Skin Disorders

8.A client is recovering from burns located on both arms, anterior chest, and both legs. The nurse realizes that this client may need which of the following dietary supplements?

1.

Vitamin B

2.

Vitamin C

3.

Vitamin D

4.

Vitamin E

ANS: 3

The skin synthesizes vitamin D by using ultraviolet light to convert 7-dehydrocholesterol in the epidermis. In the event of a large burn, the client may need vitamin D supplementation. The other vitamins are essential to normal body functioning; however, they may not be affected because of the burn.

PTS: 1 DIF: Analyze REF: Synthesis

9.The nurse, assessing a clients skin as being overly dry and scaly, would document this finding as being:

1.

poor turgor.

2.

ichthyosis.

3.

edematous.

4.

anasarca.

ANS: 2

Ichthyosis is dry, scaly skin. Poor turgor is the term used if the skin shows evidence of poor hydration. Edematous is the term used if there is an abnormal accumulation of fluid under the skin. Anasarca is a term used for generalized edema.

PTS: 1 DIF: Apply REF: Assessment of the Skin

10.A client has a nonpalpable skin lesion that is causing a change in skin color greater than 1 cm in diameter. The nurse would document this finding as being a(n):

1.

patch.

2.

macule.

3.

wheal.

4.

vesicle.

ANS: 1

A patch is a localized change in skin color of greater than 1 cm in diameter. A macule is a localized change in skin color of less than 1 cm in diameter. A wheal is localized edema in the epidermis causing irregular elevation that may be red or pale. A vesicle is an accumulation of fluid between the upper layers of the skin.

PTS: 1 DIF: Apply REF: Figure 44-6 Morphology of Primary Lesions

11.A client has an enlarged scar as a result of abdominal surgery. The nurse realizes this scar would be considered a(n):

1.

erosion.

2.

fissure.

3.

excoriation.

4.

keloid.

ANS: 4

A keloid is an enlarged scar that extends beyond the wound edges. An erosion is caused by a loss of epidermis. A fissure is a linear crack in the epidermis. An excoriation is the loss of epidermal layers of skin, exposing the dermis.

PTS: 1 DIF: Analyze REF: Figure 44-7 Morphology of Secondary Lesions

12.A client has several patches of horny, thickened skin on the palmar surface of the hands and feet. The nurse would document this finding as being:

1.

keratosis.

2.

linear.

3.

serpiginous.

4.

dermatomal.

ANS: 1

Keratosis are patches of horny, thickened skin associated with callus formation. Linear lesions have a band-like configuration. Serpiginous lesions are serpent shaped. Dermatomal lesions occur in the location of the dermatome supplied by one or more dorsal ganglia.

PTS:1DIF:Apply

REF: Box 44-2 Description and Configuration of Selected Group of Lesions

13.A school age child is diagnosed with many individual and separate skin lesions. The nurse realizes this client is experiencing the result of:

1.

measles.

2.

poison ivy.

3.

herpes zoster.

4.

insect bites.

ANS: 4

Insect bites create individual and separate lesions. Measles lesions are generalized and scattered all over the body. Poison ivy causes a linear lesion. Herpes zoster creates a lesion that is linear along a nerve root.

PTS: 1 DIF: Analyze REF: Figure 44-5 Arrangement of Lesions

MULTIPLE RESPONSE

1.The nurse is assessing the skin status of a client. Which of the following will be included in this assessment? (Select all that apply.)

1.

Personal perception of the skin problem

2.

Nutritional pattern

3.

Elimination pattern

4.

Self-concept

5.

Self-image

6.

Employment status

ANS: 1, 2, 3, 4, 5

The assessment of the skin should include personal perception of the skin problem, nutritional pattern, elimination pattern, self-concept, and self-image. Employment status is not a part of this assessment.

PTS:1DIF:Apply

REF: Table 44-2 Review of Systems Related to Skin Disorders

2.The nurse determines that a client has skin changes consistent with sun exposure. Which of the following did the nurse assess in this client? (Select all that apply.)

1.

Age spots

2.

Actinic keratoses

3.

Telangiectasias

4.

Lentigines

5.

Freckles

6.

Burrows

ANS: 1, 2, 3, 4, 5

Skin changes consistent with sun exposure include age spots, actinic keratoses, telangiectasias, lentigines, and freckles. Burrows are lesions seen with animal parasites.

PTS: 1 DIF: Analyze REF: Skin Changes Throughout the Life Span

3.The nurse is assessing a client for primary skin lesions. Which of the following would be considered primary lesions of the skin? (Select all that apply.)

1.

Crust

2.

Scales

3.

Tumors

4.

Nodules

5.

Macules

6.

Plaques

ANS: 3, 4, 5, 6

Primary skin lesions include tumors, nodules, macules, and plaques. Secondary skin lesions include crust and scales.

PTS:1DIF:Analyze

REF: Box 44-1 Primary Lesions; Figure 44-7 Morphology of secondary lesions

4.The nurse is describing the distribution and configuration of lesions. Which of the following can be used for this description? (Select all that apply.)

1.

Iris

2.

Annular

3.

Linear

4.

Keratosis

5.

Wheal

6.

Bullae

ANS: 1, 2, 3, 4

When describing the distribution and configuration of lesions, the terms iris, annular, linear, and keratosis can be used. Wheal and bullae describe primary lesions.

PTS:1DIF:Apply

REF: Box 44-2 Description and Configuration of Selected Group of Lesions

5.The nurse assesses a linear lesion along the length of a clients leg. Which diagnosis does the nurse realize is associated with linear lesions? (Select all that apply.)

1.

Drug reaction

2.

Herpes zoster

3.

Herpes simplex

4.

Hookworm

5.

Dermatitis

6.

Poison ivy

ANS: 4, 5, 6

Linear lesions are associated with poison ivy, dermatitis, or hookworm. Polycyclic lesions are associated with drug reactions. Linear lesions along a nerve root are associated with herpes zoster. Grouped or clustered lesions are associated with herpes simplex.

PTS: 1 DIF: Analyze REF: Figure 44-5 Arrangement of Lesions

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