Lewis: Medical-Surgical Nursing, 7th Edition

Test Bank

Chapter 23: Nursing Assessment: Integumentary System

MULTIPLE CHOICE

1. When obtaining a health history related to the skin, which question will assess the
patients health perception-health maintenance pattern?
a. Do you have any pain that you associate with skin problems?
b. What kinds of skin moisturizers and cosmetics do you use?
c. Has the appearance of your skin led to any changes in your social activities?
d. Have you noticed any recent skin changes such as dryness or slow healing?

Correct Answer: B
Rationale: Included in the health perception-health maintenance pattern are self-care
habits such as moisturizer and cosmetic use. Information about pain would be included in
the cognitive-perceptual pattern. Changes in social activities related to the skin
appearance would be documented in the role-relationship pattern. Data about recent skin
changes would be included in the nutritional-metabolic pattern.

Cognitive Level: Application Text Reference: p. 453

Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

2. Which assessment information documented in a patients chart indicates that the

nurse may need to continue to monitor the skin condition of an 82-year-old patient
admitted with bacterial pneumonia?
a. Skin warm and dry; longitudinal nailbed ridges noted, sparse scalp hair.
b. Skin moist and intact; no skin breakdown noted. History of allergic rashes.
c. Skin brown, no skin tenting present. States no past or current skin problems.
d. Skin pink, no open areas noted. Scattered macular brown areas on extremities.

Correct Answer: B
Rationale: 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.

Cognitive Level: Application Text Reference: p. 453

Nursing Process: Assessment NCLEX: Physiological Integrity

3. 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

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

a. palpate the dorsalis pedis and posterior tibial pulses.
b. check the temperature of the skin around the lesion.
c. elevate the patients leg.
d. press firmly on the lesion.

Correct Answer: D
Rationale: 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.

Cognitive Level: Application Text Reference: p. 454

Nursing Process: Assessment NCLEX: Physiological Integrity

4. When examining an 87-year-old home health patient, the nurse notes a musky, sour
body odor. Based on this assessment, the most appropriate nursing action is to
a. schedule a nursing assistant to help the patient bathe several times weekly.
b. teach the patient to apply a moisturizing body lotion daily.
c. consult with the health care provider to obtain a prescription for a topical
antifungal.
d. ask about use of prescription and over-the-counter (OTC) skin medications.

Correct Answer: A
Rationale: The skin odor indicates that the patients 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.

Cognitive Level: Application Text Reference: p. 454

Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

5. A dark-skinned patient has been admitted to the hospital in severe respiratory distress.
To determine whether the patient is cyanotic, the nurse will
a. assess for a bluish tinge in the sclera.
b. apply pressure to the palms of the hands.
c. check the lips and oral mucous membranes.
d. examine the nailbeds for capillary refill.

Correct Answer: C
Rationale: Inspection of the skin in dark-skinned individuals is easier in areas where the
epidermis is thin and the skin is not exposed to the sun. Assessment of the sclera is not
useful in checking for cyanosis. Application of pressure to the palms of the hands and
nailbed assessment would check for adequate circulation, but not for skin color.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cognitive Level: Application Text Reference: p. 457
Nursing Process: Assessment NCLEX: Physiological Integrity

6. When reading the admission assessment for a patient, the nurse notes that the patient
has an excoriated area on the skin of the right forearm. Which nursing action will be
included in the plan of care?
a. Apply moisturizing lotion to the area.
b. Assess the area daily for atrophy.
c. Scrub the affected area vigorously.
d. Cover the area with a sterile dressing.

Correct Answer: D
Rationale: Excoriated areas should be covered with a dressing to decrease the risk for
infection. Application of moisturizer would not help the excoriation and might lead to
infection. There is no evidence that the skin is atrophied. Scrubbing the excoriated area
would cause further damage.

Cognitive Level: Application Text Reference: p. 455

Nursing Process: Assessment NCLEX: Physiological Integrity

7. A 73-year-old asks the nurse to inspect some large reddened lumps that have recently
appeared on the legs. The nurse recognizes the lesions as angiomas and tells the
patient,
a. These skin changes are probably associated with malignancy.
b. You may need to use a more effective moisturizing lotion.
c. You will need to schedule an appointment with a dermatologist to have these
treated.
d. Angiomas are normal in aging, but they are can be associated with some
diseases.

Correct Answer: D
Rationale: Angiomas are a frequent occurrence as patients age, but they might be an
indication of systemic problems such as liver disease. They are not commonly associated
with malignancy. Moisturizer use will not impact the appearance or occurrence of
angiomas. There is no indication that the patient needs referral to a dermatologist.

Cognitive Level: Application Text Reference: p. 457

Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

8. A patient in the dermatology clinic is scheduled for removal of a 10-mm,
multicolored, irregular mole from the upper back. The nurse will plan to teach the
patient about a (an)
a. shave biopsy.
b. punch biopsy.
c. incisional biopsy.
d. excisional biopsy.

Correct Answer: C
Rationale: 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.

Cognitive Level: Application Text Reference: p. 458

Nursing Process: Planning NCLEX: Physiological Integrity

9. During assessment of the patients skin, the nurse observes a ring of small, raised,
blister-like lesions filled with serous fluid on the patients right temple. The nurse
should document the configuration and distribution of these lesions as
a. discoid and symmetric.
b. annular and grouped.
c. gyrate and diffuse.
d. linear and zosteriform.

Correct Answer: B
Rationale: The description of the lesions is consistent with the terms annular and
grouped. The other terminology would describe lesions with a different appearance.

Cognitive Level: Comprehension Text Reference: p. 456

Nursing Process: Assessment NCLEX: Physiological Integrity

10. 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
a. skin atrophy.
b. keloid formation.
c. lichenification.
d. skin varicosity.

Correct Answer: C

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

 Rationale: 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.

Cognitive Level: Comprehension Text Reference: p. 457

Nursing Process: Assessment NCLEX: Physiological Integrity

11. The nurse notes all these changes in the skin of a 95-year-old patient who is being
admitted to an assisted-living facility. Which change will be of most concern to the
nurse?
a. Petechiae present on the chest and abdomen
b. Numerous varicosities noted on both legs
c. Several dry, scaly patches on the face
d. Fingernails have multiple longitudinal ridges

Correct Answer: A
Rationale: 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 patients 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.

Cognitive Level: Application Text Reference: p. 457

Nursing Process: Assessment NCLEX: Physiological Integrity

12. The nurse is preparing to send a culture for a patient who has a possible herpes zoster
infection on the chest. Which action is appropriate?
a. Rupture one of the vesicles and take a specimen from the center of the lesion.
b. Aspirate a specimen from one of the bullae with a sterile 27-gauge needle.
c. Take a specimen by swabbing the infected area with a sterile applicator.
d. Obtain aerobic and anaerobic specimens using the appropriate culture materials.

Correct Answer: A
Rationale: For lesions with vesicles or bullae, the lesion should be opened using sterile
technique and a specimen obtained from the center of the lesion. Aspiration of bullae
would present a risk of injury to the patient. Swabbing the area would be likely to result
in obtaining normal skin flora rather than the infectious agent. Anaerobic cultures would
be unnecessary for an infection on the skin of the chest and would unnecessarily increase
the cost of the culture.

Cognitive Level: Application Text Reference: p. 458

Nursing Process: Assessment NCLEX: Physiological Integrity

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

MULTIPLE RESPONSE

1. 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.)
a. alopecia.
b. intertrigo.
c. wrinkling.
d. melanoma.
e. telangiectasia.
f. actinic keratosis.

Correct Answer: C, D, E, F
Rationale: A patient who works as a roofer is at risk for integumentary lesions caused by
sun exposure such as wrinkling, melanoma, telangiectasia, and actinic
keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.

Cognitive Level: Application Text Reference: p. 454

Nursing Process: Planning NCLEX: Physiological Integrity

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.