Concept 24: Tissue Integrity My Nursing Test Banks

Concept 24: Tissue Integrity

Test Bank

MULTIPLE CHOICE

1. A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself?

a.

Limit the time you spend in the sun.

b.

Monitor for signs of infection.

c.

Monitor spots for color change.

d.

Use skin creams to prevent drying.

ANS: C

The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

REF: 254 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?

a.

Obtaining a complete blood count (CBC)

b.

Protection from excessive heat

c.

Protection from excessive UV exposure

d.

Instructing the patient to take their multivitamin prior to treatment

ANS: C

Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

REF: 255

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment Safety: Safety and Infection Control

3. A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?

a.

Apply the cream generously to affected areas.

b.

Apply a thin coat to affected areas.

c.

Apply a thin coat to affected areas; avoid the face and groin.

d.

Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C

The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

REF: 253

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?

a.

Decreasing pain

b.

Decreasing pruritus

c.

Preventing infection

d.

Promoting drying of lesions

ANS: B

Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

REF: 255

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following?

a.

Apply sunscreen 1 hour prior to exposure.

b.

Drink plenty of water to prevent hot skin.

c.

Use vitamins to help prevent sunburn by replacing lost nutrients.

d.

Apply sunscreen 30 minutes prior to exposure.

ANS: D

Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

REF: 254 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching?

a.

I wear a hat and sit under the umbrella when not in the water.

b.

I dont bother with sunscreen on overcast days.

c.

I use a sunscreen with the highest SPF number.

d.

I wear a UV shirt and limit exposure to the sun by covering up.

ANS: B

The suns rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

REF: 254 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate

a.

Candida albicans.

b.

group A beta-hemolytic streptococci.

c.

Staphylococcus aureus.

d.

Streptococcus pyogenes.

ANS: D

Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

REF: 249

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is conducting community education classes on skin cancer. One participant says to the nurse: I read that most melanomas occur on the face and arms in fair-skinned women. Is this true? The nurses most helpful response would be which of the following?

a.

That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.

b.

That is correct, because the face and arms are exposed more often to the sun.

c.

That is not correct. Melanoma occurs on the top of the head in men but is rare in women.

d.

That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.

ANS: A

Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

REF: 250 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

9. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to

a.

bathe and dry the skin vigorously to stimulate circulation.

b.

keep the head of the bed elevated 30 degrees.

c.

limit intake of fluid and offer frequent snacks.

d.

turn the patient at least every 2 hours.

ANS: D

The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

REF: 254

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10. A patient asks the nurse what the purpose of the Woods light is. Which response by the nurse is accurate?

a.

We will put an anesthetic on your skin to prevent pain.

b.

The lamp can help detect skin cancers.

c.

Some patients feel a pressure-like sensation.

d.

It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.

ANS: D

The Woods light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

REF: 253 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

Leave a Reply