Chapter 23: Nursing Assessment: Integumentary System

Chapter 23: Nursing Assessment: Integumentary System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. When the nurse is assessing a 42-year-old woman, the patient states that she is using
topical fluorouracil (Efudex, Fluoroplex) to treat actinic keratoses on her face. Which
additional information will be most important for the nurse to obtain?
a. Method of birth control the patient is using
b. History of extensive sun exposure by the patient
c. Length of time the patient has used the medication
d. Appearance of the treated areas on the patient’s face
ANS: A
Since fluorouracil is teratogenic, it is essential that the patient use a reliable method of
birth control. The other information also will be obtained by the nurse, but lack of
reliable birth control has the most potential for serious adverse medication effects.
DIF: Cognitive Level: Application REF: 441
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. Which assessment information documented in a patient’s 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. “Scattered macular brown areas on extremities”
b. “Skin brown and wrinkled, skin tenting on forearm”
c. “Longitudinal nail bed ridges noted, sparse scalp hair”
d. “Skin moist and intact; states history of allergic rashes”
ANS: D
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.
DIF: Cognitive Level: Application REF: 438-439
TOP: Nursing Process: Assessment MSC: 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
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
Test Bank 23-2
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: Application REF: 443
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. When examining a homebound patient, the home health nurse notes a musky, sour body
odor. Based on this assessment, the most appropriate nursing action is to
a. teach the patient to apply a moisturizing body lotion daily.
b. ask about use of over-the-counter (OTC) skin medications.
c. ask the health care provider about a prescription for a topical antifungal.
d. schedule nursing assistive personnel to help with bathing several times weekly.
ANS: D
The skin odor indicates that the patient’s 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.
DIF: Cognitive Level: Application REF: 438 | 443
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance