Chapter 23&24/Chapter 60&61- Assessment and management of Integumentary Function. Questions with Accurate Answers. Rated A+
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Assessment and management of Integumentary Functi
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Assessment And Management Of Integumentary Functi
A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?
a. History of sun exposure by the patient
b. Method of birth control used by the patient
c. L...
a 38 year old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face which additional assessment information will be most important for the nurse to obtai
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Assessment and management of Integumentary Functi
Assessment and management of Integumentary Functi
Assessment and management of Integumentary Functi
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Chapter 23&24/Chapter 60&61-
Assessment and management of
Integumentary Function. Questions with
Accurate Answers. Rated A+
A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her
face. Which additional assessment information will be most important for the nurse to obtain?
a. History of sun exposure by the patient
b. Method of birth control used by the patient
c. Length of time the patient has used fluorouracil
d. Appearance of the treated areas on the patient's face - ✔✔ANS: B
Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control.
The other information is also important for the nurse to obtain, but lack of reliable birth control has the
most potential for serious adverse medication effects.
Note:
actinic keratoses- rough scaly patch on skin that develops from sun exposure
Teratogenic- disturbance of the development of embryo which will cause birth defects.
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of
most concern for the nurse?
a. Reports a history of allergic rashes
b. Scattered macular brown areas on extremities
c. Skin brown and wrinkled, skin tenting on forearm
d. Longitudinal nail bed ridges noted; sparse scalp hair - ✔✔ANS: A
Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most
concerned about her history of allergic rashes. The nurse needs to do further assessment of possible
causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially
antibiotics. The assessment data in the other response would be normal for an older patient.
,The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's
ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
a. Elevate the patient's leg.
b. Press firmly on the lesion.
c. Check the temperature of the skin around the lesion.
d. Palpate the dorsalis pedis and posterior tibial pulses. - ✔✔ANS: B
If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration
will remain when direct pressure is applied to the lesion. 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.
When examining an older patient in the home, the home health nurse notices irregular patterns of
bruising at different stages of healing on the patient's body. Which action should the nurse take first?
a. Discourage the use of throw rugs throughout the house.
b. Ensure the patient has a pair of shoes with non-slip soles.
c. Talk with the patient alone and ask about what caused the bruising.
d. Notify the health care provider so that x-rays can be ordered as soon as possible. - ✔✔ANS: C
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in
different stages of resolution. These may be indications of other health problems or abuse, and should
be further investigated. It is important that the nurse interview the patient alone because, if
mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the
abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the
patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurse's
first nursing action is to further assess the patient.
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the
nurse best assess this patient for cyanosis?
a. Assess the skin color of the earlobes.
b. Apply pressure to the palms of the hands.
c. Check the lips and oral mucous membranes.
d. Examine capillary refill time of the nail beds. - ✔✔ANS: C
,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.
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot.
Which items should the nurse gather for this procedure?
a. Sterile gloves
b. Patch test instruments
c. Cotton-tipped applicators
d. Local anesthetic, syringe, and intradermal needle - ✔✔ANS: C
Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators.
Sterile gloves are not needed because it is not a sterile procedure. Local injection is not needed because
the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to
specific testing material, not for obtaining fungal specimens.
When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient.
Which action should the nurse take next?
a. Assess the patient for evidence of liver disease.
b. Discuss the adverse effects of sun exposure on the skin.
c. Teach the patient about possible skin changes with aging.
d. Suggest that the patient make an appointment with a dermatologist. - ✔✔ANS: A
Angiomas are a common occurrence as patients get older, 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 teach 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.
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole
from the upper back. The nurse should prepare the patient for which type of biopsy?
a. Shave biopsy
b. Punch biopsy
c. Incisional biopsy
, d. Excisional biopsy - ✔✔ANS: C
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.
During assessment of the patient's skin, the nurse observes a similar pattern of small, raised lesions on
the left and right upper back areas. Which term should the nurse use to document these lesions?
a. Confluent
b. Zosteriform
c. Generalized
d. Symmetric - ✔✔ANS: D
The description of the lesions indicates that they are grouped. The other terms are inconsistent with the
description of the lesions.
A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment
finding will the nurse expect?
a. Hypertrophied scars on both ankles
b. Thickening of the skin around the ankles
c. Yellowish-brown skin around both ankles
d. Complete absence of melanin in both ankles - ✔✔ANS: B
Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification
results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence
of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo,
keloids, and jaundice do not usually occur as a result of scratching the skin.
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health
care provider?
a. Several dry, scaly patches on the face
b. Numerous varicosities noted on both legs
c. Dilation of small blood vessels on the face
d. Petechiae present on the chest and abdomen - ✔✔ANS: D
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