Question 1

A 50-year-old patient is concerned because several firm, deep-red papules have appeared on both legs and the number is increasing. The nurse should recognize these as which type of lesion?

Accepted Answer

Cherry angiomas are firm, deep-red papules that commonly appear on the trunk, arms, and legs of individuals over 30 years old. They are usually benign and do not require treatment unless they become irritated or bleed.

Question 2

While recording the health history, the nurse learns that a patient has worked at a landfill for the last 35 years. Why is this information important?

Accepted Answer

Working at a landfill involves exposure to potential environmental toxins, which can increase the risk of developing certain health conditions. It is important for the nurse to take note of this information when assessing the patient's overall health and risk factors.

Question 3

While performing the assessment for bilateral symmetrical skin temperature, the nurse finds that the skin temperature of the patient's left hand is much cooler than the skin temperature of the right hand. The nurse should conduct additional assessment for which possible conditions?. Select all that apply.

Accepted Answer

A,D

Question 4

The nurse notes a yellowish discoloration of the patient's skin, but it does not involve the sclera or mucous membranes. The nurse should the patient about which history?

Accepted Answer

The yellowish discoloration of the skin without involvement of the sclera or mucous membranes suggests carotenemia, which is often related to dietary intake, particularly high consumption of foods rich in carotene like carrots and sweet potatoes.

Question 5

After assisting a patient to turn in bed, the nurse notes that the patient's leg has indentations that clearly show where the leg was supported by the nurse's hand. How would the nurse document this finding?

Accepted Answer

Pitting edema is the presence of indentation or "pit" in the skin when pressure is applied due to fluid accumulation in the tissue. It is often seen in lower extremities and is commonly assessed using a 1+ to 4+ scale based on the depth and duration of the pit. The nurse should document the presence of pitting edema in the patient's leg to provide accurate information for further assessment and management.

Question 6

Which information would the nurse identify as a patient's chief complaint about a skin disorder?

Accepted Answer

The patient's chief complaint is typically the main reason they are seeking medical attention. In this case, the patient is stating that they have a rash on their arm, which is a specific symptom they are concerned about. The other options provide additional information but do not clearly identify the patient's chief complaint.

Question 7

A patient is admitted with edematous lower extremities. The nurse palpates the patient's skin and finds that when pressure is applied, a deep indentation occurs and lasts for a short time. The nurse would document this finding as ____ + pitting edema.

Accepted Answer

The answer of A patient is admitted with edematous lower...

Question 8

During a physical exam of the patient's nails, the nurse depresses the nail edge to blanch it, and then releases it. What is the nurse assessing with this technique?

Accepted Answer

The nurse is assessing capillary refill, which is the time it takes for blood to return to the capillary bed after it has been blanched. This can indicate if there is adequate blood flow to the area.

Question 9

A patient is very concerned about a vesicle on the lip that extends onto the skin. The patient's history reveals this vesicle has been present for 3 days. Which assessment would the nurse ask?

Accepted Answer

Asking if the patient has ever had a cold sore or herpes infection on their lip is relevant because herpes simplex virus type 1 (HSV-1) typically causes cold sores, which can present as vesicles on the lip that extend onto the skin. Understanding the patient's history of herpes infections can help determine if this is a recurrence or a new infection.

Question 10

While palpating the nail bed of an African American patient, the nurse notes that the nails have linear bands along the nail edge. How would the nurse evaluate this finding?

Accepted Answer

Linear bands along the nail edge are a common finding in dark-skinned individuals and are typically not indicative of a health problem.

Question 11

A patient has been admitted with damage to the skin over both lower legs. The nurse immediately institutes measures to help prevent infection. The nurse's rationale for this action relates to damage of which cells?. Select all that apply.

Accepted Answer

Langerhans' cells and dermal dendrocytes are involved in the immune response and help prevent infection. Keratinocytes form a physical barrier to protect against pathogens. Damage to these cells can increase the risk of infection.

Question 12

The emergency department nurse palpates a patient's skin to assess its texture. The nurse manager would evaluate that this nurse is following protocol if which technique is used?

Accepted Answer

The technique of palpating the skin with the palmar surface of the fingers and finger pads is the standard protocol for assessing skin texture. The dorsal surface of the hand and anterior surface of the wrist are not as sensitive and may miss subtle changes in texture. Placing the palm of the hand on the skin may also not provide enough sensitivity to detect texture changes.

Question 13

How should the nurse conduct the physical examination of a patient's skin?

Accepted Answer

Ethnic differences can affect the appearance and characteristics of the skin, so the nurse should be aware of these differences when conducting a physical examination.

Answer: C
 It is recommended to begin examining the least-exposed areas first, such as the back, to avoid disrupting any skin lesions or irritations that may occur where clothing rests against the skin.

Therefore, the best choices are B and C.

Question 14

Which technique would the nurse use to assess a patient's skin turgor?

Accepted Answer

To assess a patient's skin turgor, the nurse would grasp a fold of the patient's skin between the forefinger and thumb. This helps to evaluate the elasticity and hydration level of the skin. Palpating the skin can help assess texture, temperature, and moisture level but does not provide information on skin turgor. Fluid intake and blanching of the nail bed are not directly related to assessing skin turgor.

Question 15

The nurse is conducting an integumentary assessment on an older adult. Which patient statement would the nurse prioritize as it does not reflect a normal age-related change?

Accepted Answer

While all answer choices may be seen in older adults, excessive skin greasiness that persists despite frequent washing would not be considered a normal age-related change and may indicate a health issue such as hormone imbalances or medication side effects. Thin skin, slow nail growth, and gray hair are all commonly associated with aging.

Question 16

A patient from Southeast Asia who has been ill with influenza is admitted with self-inflicted open sores and bruising on both forearms. When questioned about the wounds, the patient states that they were inflicted to aid the healing process. What should the nurse consider when assessing these wounds?

Accepted Answer

Self-inflicted wounds for healing purposes may be a cultural practice in some Southeast Asian countries, such as Thailand and Cambodia, where this practice is known as "coining" or "gua sha." As a nurse, it is important to be culturally sensitive and understanding of different practices and beliefs, and to assess the wounds for signs of infection or other medical concerns.

Question 17

A patient with a history of chronic allergic dermatitis is concerned because of an area where the skin has become thickened and rough. How would the nurse document this lesion?

Accepted Answer

Lichenification is the thickening and roughening of the skin due to chronic irritation or scratching, often seen in patients with chronic allergic dermatitis. Excoriation is the loss of superficial layers of skin due to scratching or rubbing. Ulceration is the loss of entire layers of skin or deeper tissues. Ecchymosis is a bruise or discoloration of the skin due to bleeding underneath the skin.

Question 18

During a conversation with the nurse, a patient says, "I avoid going outside when the sun is shining because I don't want to get skin cancer." The nurse should inform the patient that sun avoidance may predispose the patient to which condition?

Accepted Answer

Sun exposure is a primary source of vitamin D, which is required for strong bones, immune function, and other physiological processes. Prolonged sun avoidance may lead to vitamin D deficiency. Hypokalemia, hypernatremia, and hypercholesterolemia are not directly related to sun exposure or avoidance.

Question 19

During completion of a health history, the patient reports being allergic to strawberries. What additional questions should the nurse ask?. Select all that apply.

Accepted Answer

The nurse should ask about the symptoms of the allergic reaction (B), how the patient treats it (C), when the last reaction occurred (D), and if there are other food allergies (E) to fully understand the allergy and its management.

Question 20

The nurse discovers a vascular lesion on a patient's chest. What should the nurse check to help determine if the lesion is petechiae or telangiectasia?

Accepted Answer

Checking if the lesion blanches (loses color temporarily when pressure is applied) can help determine if the lesion is petechiae or telangiectasia. Petechiae do not blanch, while telangiectasia often do blanch. The other options (scaliness, raisedness, and pain) are not specific to either petechiae or telangiectasia.

Quiz 58: Nursing Assessment of the Patient With Integumentary Disorders