Chapter 23: Nursing Assessment: Integumentary System

Test Bank

MULTIPLE CHOICE

1. 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 patients 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.

DIF: Cognitive Level: Apply (application) REF: 419

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. 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.

DIF: Cognitive Level: Apply (application) REF: 418-419

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged
patients ankle. How should the nurse determine if the lesion is related to intradermal
bleeding?
a. Elevate the patients 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.

DIF: Cognitive Level: Apply (application) REF: 421

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. When examining an older patient in the home, the home health nurse notices irregular patterns
of bruising at different stages of healing on the patients 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.

DIF: Cognitive Level: Apply (application) REF: 421

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

5. 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.

DIF: Cognitive Level: Apply (application) REF: 421

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. 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.

DIF: Cognitive Level: Apply (application) REF: 425

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. 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.

DIF: Cognitive Level: Apply (application) REF: 422

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

8. 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.

DIF: Cognitive Level: Apply (application) REF: 425

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. During assessment of the patients 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.

DIF: Cognitive Level: Understand (comprehension) REF: 421

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. 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.

DIF: Cognitive Level: Understand (comprehension) REF: 422

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. 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
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 will also require ongoing monitoring or
intervention by the nurse, they do not indicate a need for urgent action.

DIF: Cognitive Level: Apply (application) REF: 417

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. When taking the health history of an older adult, the nurse discovers that the patient has
worked in the landscaping business for 40 years. The nurse will plan to teach the patient about
how to self-assess for which clinical manifestations (select all that apply)?
a. Vitiligo
b. Alopecia
c. Intertrigo
d. Erythema
 e. Actinic keratosis
ANS: D, E
A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure
such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated
with excessive sun exposure.

DIF: Cognitive Level: Analyze (analysis) REF: 417 | 422

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. Which activities can the nurse working in the outpatient clinic delegate to a licensed
practical/vocational nurse (LPN/LVN) (select all that apply)?
a. Administer patch testing to a patient with allergic dermatitis.
b. Interview a new patient about chronic health problems and allergies.
c. Apply a sterile dressing after the health care provider excises a mole.
d. Teach a patient about site care after a punch biopsy of an upper arm lesion.
e. Explain potassium hydroxide testing to a patient with a superficial skin infection.
ANS: A, C
Skills such as administration of patch testing and sterile dressing technique are included in
LPN/LVN education and scope of practice. Obtaining a health history and patient education
require more critical thinking and registered nurse (RN) level education and scope of practice.

DIF: Cognitive Level: Apply (application) REF: 15-16

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment