Deck 48: Assessment of the Integumentary System

Question 1

In a highly pigmented client, the nurse would best assess for erythema by

A) follicular accentuation.
B) induration.
C) reddening of the skin.
D) striation.

Answer 1

follicular accentuation.

Question 2

After a client's surgical excisional biopsy, the nurse would apply

A) antibiotic ointment and a dry dressing.
B) Band-Aids only.
C) hydrocolloid dressing only.
D) petrolatum gauze and paper tape.

Answer 2

antibiotic ointment and a dry dressing.

Question 3

After tape is applied for skin patch testing, the nurse would include in the client's instructions to return to the clinic for tape removal and initial reading in

A) 24 hours.
B) 48 hours.
C) 3 days.
D) 7 days.

Answer 3

48 hours.

Question 4

A client has elevated lesions that contain serous fluid. The nurse would document these as

A) nodules.
B) pustules.
C) vesicles.
D) wheals.

Question 5

The nurse caring for a child with impetigo notes that some of the lesions on the child's skin appear elevated and contain purulent material. Secondary lesions are also present and are honey colored. The nurse would document these lesions as

A) cysts and bullae.
B) nodules and scales.
C) pustules and crusts.
D) vesicles and excoriations.

Question 6

When the nurse lifts the client's foot to clean it during bathing, the nurse notices that it is cool to the touch. The nurse's most appropriate initial action would be to

A) compare the temperature of the foot with the client's other foot.
B) document the finding on the client's chart.
C) inspect hair distribution on the lower half of the leg.
D) Place the extremity under a blanket and continue the bath.

Question 7

A client is undergoing a lengthy series of treatments for a skin disorder. The best method of documenting the client's experience with the treatments is for the nurse to

A) document the lesions clearly at each visit using proper terminology.
B) draw the distribution and characteristics of the lesions occasionally.
C) have the client record ongoing changes and include them in the record.
D) photograph the lesions at each clinic visit and use them for comparison.

Question 8

On examination of a client, the nurse notes elevated, solid, brown skin lesions that are each 0.5 cm in size. The nurse would describe these lesions as

A) papules.
B) plaques.
C) macules.
D) nodules.

Question 9

The nurse would explain to a client that an "allergy" differs from an "irritation" in that an allergy

A) affects the skin and mucous membranes only.
B) is an immune response.
C) is inconsistent.
D) can be totally desensitized.

Question 10

The nurse observes crusty brown lesions covering a client's back. To assist in identifying a possible cause, the most helpful question the nurse would ask the client is

A) "Have you recently changed laundry detergents?"
B) "How much does the rash itch?"
C) "What did the rash look like when you first noticed it?"
D) "What did you eat last night?"

Question 11

The nurse would explain to a client that examples of primary skin lesions include (Select all that apply)

A) cysts.
B) macules.
C) scales.
D) plaque.
E) pustules.
F) wheals.

Question 12

The nurse would record the presence of a lichenification as a

A) complicated lesion.
B) primary lesion.
C) secondary lesion.
D) simple lesion.

Question 13

When the client taking chlorpromazine (Thorazine), phenytoin (Dilantin), penicillin, and a multivitamin complains of a sunburn-like rash on the face and arms, the nurse would suspect the cause to be the

A) dilantin.
B) multivitamin.
C) penicillin.
D) tetracycline.