Question 1

When the nurse is assessing a 42-year-old woman, the patient states that she is using topical fluorouracil (Efudex, Fluoroplex) to treat actinic keratoses on her face. Which additional information will be most important for the nurse to obtain?

Accepted Answer

Since fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information also will be obtained by the nurse, but lack of reliable birth control has the most potential for serious adverse medication effects.

Question 2

The nurse is preparing to obtain a culture from a patient who has a possible fungal infection in the groin area. Which action is appropriate?

Accepted Answer

Fungal cultures are obtained by swabbing the affected area of the skin. The other actions might be used for obtaining other types of specimens.

Question 3

When examining a homebound patient, the home health nurse notes a musky, sour body odor. Based on this assessment, the most appropriate nursing action is to

Accepted Answer

The skin odor indicates that the patient's hygiene is poor and that assistance with bathing is needed. Although elderly patients may need moisturizing lotions and should be asked about use of skin medications, the assessment data do not indicate that these are the most appropriate actions. An antifungal would be indicated if the nurse noticed a yeast odor.

Question 4

The nurse notes several angiomas on the legs of a 73-year-old patient. Which action should the nurse take next?

Accepted Answer

Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.

Question 5

The nurse notes these abnormalities on the skin of a 95-year-old patient who is being admitted to an assisted living facility. Which abnormality is the priority to discuss immediately with the health care provider?

Accepted Answer

Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.

Question 6

During assessment of the patient's skin, the nurse observes a ring of small, raised, discrete lesions filled with serous fluid on the patient's right temple. When documenting the lesions, the nurse will describe the lesions as

Accepted Answer

The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions.

Question 7

When taking the health history for a patient, the nurse discovers that the patient works as a roofer. The nurse will plan to teach the patient about how to self-assess for clinical manifestations of (select all that apply)

Accepted Answer

A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.

Question 8

A patient has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. To determine whether the lesion is related to blood vessel dilation, the nurse will

Accepted Answer

If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.

Question 9

A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine whether the patient is cyanotic, the nurse will

Accepted Answer

Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation, but not for skin color.

Question 10

Which assessment information documented in a patient's chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old patient admitted with bacterial pneumonia?

Accepted Answer

Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other response would be normal for an elderly patient.

Question 11

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse will plan to teach the patient about

Accepted Answer

An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant; a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.

Question 12

A patient reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for

Accepted Answer

Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.

Quiz 23: Nursing Assessment: Integumentary System