Chapter 51- Patient Assessment- Integumentary System. My Nursing Test Banks

 

1.

A nurse is completing an integumentary assessment on a patient. Which of the following specific techniques is part of this assessment? Select all that apply.

A)

Auscultation

B)

Tapping

C)

Palpation

D)

Comparison

E)

Identification

F)

Inspection

2.

A patient is receiving education related to skin cancer. The nurse explains to the patient that skin lesions are variously described by which of the following? Select all that apply.

A)

Odor

B)

Color

C)

Texture

D)

Shape

E)

Cause

F)

General appearance

3.

A nurse compares normal to abnormal vascular findings during a skin assessment. Which of the following are considered normal vascular findings? Select all that apply.

A)

Purpura

B)

Cherry angioma

C)

Spider angioma

D)

Nevus flammeus

E)

Urticaria

F)

Capillary hemangioma

4.

Skin color is determined by the presence of which of the following pigments? Select all that apply.

A)

Carboxyhemoglobin

B)

Deoxyhemoglobin

C)

Melanin

D)

Pallor

E)

Hemoglobin

F)

Carotene

5.

Which of the following are characteristic of nonpitting edema? Select all that apply.

A)

Redness

B)

Fluid leakage

C)

Tenderness

D)

Dryness

E)

Scaling

F)

Warmth

6.

Which of the following provide information about the health of the skin and may yield information about the patients fluid volume balance? Select all that apply.

A)

History

B)

Mobility

C)

Temperature

D)

Color

E)

Turgor

F)

Moisture

7.

Erythema manifests as a reddish tone in light-skinned people and a deeper brown or purple tone in dark-skinned people. Erythema is associated with which of the following disorders and diseases? Select all that apply.

A)

Liver disease

B)

Cellulitis

C)

Lung disease

D)

Inflammation

E)

Tissue trauma

F)

Surgical wounds

8.

A nurse is providing education to a patient with diabetes as it relates to yeast (candidiasis) infections. In order to assess patient understanding, the nurse asks the patient to describe symptoms of a yeast infection. Which of the following may the patient include in the description? Select all that apply.

A)

Red sores on oral mucosa

B)

White patches on the tongue and/or oral mucosa

C)

Red scaly rash on abdomen

D)

Whitish pseudomembrane, and macropapular lesions in the groin

E)

Erythema under the breasts

F)

Petechial rash under abdominal folds and breasts

9.

A nurse is inspecting the patients skin for signs of melanoma. Which of the following may the nurse find during the assessment if the patient exhibits signs of melanoma? Select all that apply.

A)

Pale red rash

B)

Lesions that are either dark brown or black in color

C)

Lesions with irregular borders

D)

Raised lesions with hair growing from them

E)

Lesions greater than 6 mm

F)

Lesions greater than 3 mm

10.

A Caucasian patient and an African-American patient are exhibiting signs of jaundice. Which of the following signs did the African-American patient exhibit? Select all that apply.

A)

Yellow tone to skin

B)

Yellow-greenish color of soles of feet

C)

Yellow color of hands

D)

Yellow-greenish color of palms of hands

E)

Yellow-greenish color of skin

F)

Yellow-greenish color of hair

11.

The nurse is examining the skin of a critically ill patient. What technique should the nurse?

A)

Inspect the appearance of the skin every 12 hours.

B)

Inspect only the anterior body skin every 12 hours.

C)

Auscultate for bruits over skin lesions when found.

D)

Percuss the borders of skin lesions when found.

12.

A critically ill patient with a Hispanic and American Indian ethnic background is in hemorrhagic shock. The nurse notices that the patients skin is yellowish brown and the conjunctiva, oral mucosa, and nail beds are ashen gray. What variation in skin color does the nurse document?

A)

Pallor

B)

Cyanosis

C)

Jaundice

D)

Erythema

13.

The patient is in decompensated shock. What abnormal variation in peripheral skin color does the nurse expect to find?

A)

Pallor

B)

Cyanosis

C)

Erythema

D)

Jaundice

14.

The patient has a large dark-red area involving the left lower face and jaw. There is no swelling or pain or history of trauma to the face or jaw. The patient states this mark has been present as long as she can remember. What is the most appropriate nursing action?

A)

Obtain radiographs of the head and neck.

B)

Report symptoms to adult protective services.

C)

Document findings in permanent record.

D)

Obtain clotting panel laboratory studies.

15.

An elderly patient is admitted to the emergency department for treatment of an acute urinary tract infection with possible sepsis. During the admission examination, the nurse notices multiple ecchymoses of varying ages over both ulnar edges. The patient denies falling and seems reluctant to answer any questions about the ecchymoses. The patients daughter states that the patient falls down often, and she appears impatient with her mother. The patients gait and balance are normal, and the patient is oriented and otherwise cooperative. What is the best nursing action?

A)

Obtain x-rays of the forearms.

B)

Evaluate serum electrolyte values.

C)

Report the situation to protective services.

D)

Apply a vest restraint to the patient.

16.

The patient is receiving the second dose of an intravenous antibiotic and complains of urticaria that is rapidly spreading all over the his body. What is the most appropriate nursing action?

A)

Slow the medication administration rate.

B)

Notify the physician if symptoms worsen.

C)

Monitor vital signs frequently.

D)

Discontinue the medication at once.

17.

A patient is being treated for sepsis with several intravenous broad-spectrum antibiotics. After a week of therapy, the nurse notices a rash in the groin that is erythematous, with white papules and pustules. There is also an odor similar to bread rising. What condition does the nurse suspect?

A)

Urticaria from drug allergy

B)

Hepatic frost from liver failure

C)

Candidiasis from yeast overgrowth

D)

Atypical rash from venereal disease

18.

The patient has systemic inflammatory response syndrome (SIRS) and very severe third spacing of fluid. During routine assessment, the nurse finds that the patients skin appears generally swollen, red, and shiny, and the nurse is unable to depress the surface of the skin. What type or degree of edema is present?

A)

Nonpitting

B)

2+

C)

3+

D)

4+

19.

During routine assessment of a critically ill patient, the nurse is able to indent the skin on the dorsal surface of the foot 4 mm, and the skin rebounds in a few seconds. What degree or type of edema is present?

A)

Nonpitting edema

B)

2+ pitting edema

C)

3+ pitting edema

D)

4+ pitting edema

20.

A critically ill patient is on mechanical ventilation through a tracheostomy and is receiving enteral nutrition through a gastrostomy tube. External fixation devices are in place for multiple fractures. Because of persistent hemodynamic instability, the patient spends a great deal of time in the supine position. What areas of the patients body are most likely to develop pressure ulceration?

A)

Greater trochanter

B)

Dorsal feet and toes

C)

Ischial areas

D)

Occipital areas

21.

The nurse completes an assessment using the Braden scale on a critically ill patient. The patients score is 9. What is the best nursing action?

A)

Increase frequency of assessment to every 4 hours.

B)

Consult skin care specialist nurse for recommendations.

C)

Turn patient every 2 hours around the clock.

D)

Evaluate patients nutritional status.

22.

The patient reports changes in a mole that are consistent with the development of melanoma. What mole characteristic would the nurse least expect to assess?

A)

Irregular borders

B)

Dark brown color

C)

Located on upper arm

D)

Asymmetric shape

Answer Key

1.

C, F

2.

B, D, E, F

3.

B, D, F

4.

B, C, E, F

5.

A, C, F

6.

B, E

7.

B, D, F

8.

B, D, E

9.

B, C, E

10.

B, D

11.

A

12.

B

13.

B

14.

C

15.

C

16.

D

17.

C

18.

A

19.

B

20.

D

21.

B

22.

C

Page 1

Leave a Reply