Chapter 22: Assessment of Integumentary System

Chapter 22: Assessment of Integumentary System

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A 35-yr-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 contraception 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 contraception has the most potential for serious adverse medication effects.

 

DIF:    Cognitive Level: Analyze (analysis)                                  REF:   400

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

 

2. Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse?

a.	Brown macules on extremities
b.	Reports a history of allergic rashes
c.	Skin wrinkled with tenting on both hands
d.	Longitudinal nail ridges and sparse scalp hair

 

 

ANS:  B

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:               398

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 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.

 

DIF:    Cognitive Level: Apply (application)           REF:               401

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 patient’s body. Which action should the nurse take first?

a.	Ensure the patient wears shoes with nonslip soles.
b.	Discourage using throw rugs throughout the house.
c.	Talk with the patient alone and ask about the bruising.
d.	Notify the health care provider so that radiographs can be ordered.

 

 

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. Radiographs 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: Analyze (analysis)                                  REF:   401

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 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:               403

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