Chapter 56: New Integumentary System Introduction Chapter 57: Skin Disorders

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Displaying her hands, a patient asks, "Do you think my liver is OK? Look at all these liver spots!" Which is the most appropriate nursing response?

The spots are normal aging changes and have nothing to do with your liver."

A confused patient has been restrained because of combativeness and hyperactivity. Which skin assessment may occur as a result of the restraints?

Senile purpura

Which information should a nurse ask about when taking the functional assessment of a patient with a skin disorder?

Exposure to chemicals or irritants

A daughter of an older adult patient who has just returned from surgery is distressed about her father's pale, cold hands and feet. Which is the best response by the nurse after covering the patient with an extra blanket?

When patients have blood loss during surgery, superficial vessels close off temporarily, resulting in cold extremities."

Which information should a nurse provide to a patient with vitiligo receiving phototherapy?

Wear protective clothing."

A nurse is screening patients that the plastic surgeon is considering for phototherapy. Which patient should the nurse exclude?

A 34-year-old woman with lupus erythematosus

Which age-related skin changes should a nurse anticipate when performing a physical assessment on an 80-year-old man? (Select all that apply.)

Increased nasal hair, Increased nasal hair, Increased hair on the helix of the ear, presence of seborrheic kertosis

Which conditions can be improved with negative pressure therapy? (Select all that apply.)

Pressure ulcers, Skin grafts, Dehisced surgical wounds

When assessing the capillary refill, a nurse should document as normal a refill time of____seconds

A nurse is caring for a patient with pruritus. Which implementation can the nurse perform without a physician's order?

Apply lubricant to unbroken skin.

Which action should a nurse implement to make a patient with atopic dermatitis more comfortable?

Instruct the patient to wear loose clothing

Which sign or symptom suggests that a patient with skin breakdown is developing a systemic infection?

Temperature that has risen to 101° F

Which implementation is appropriate for a patient with severe psoriasis who has an altered self-concept?

Touching the patient often

A patient with severe psoriasis who is to be treated with the systemic drug methotrexate sodium anxiously asks, "Is this cancer drug safe? Are there some side effects I need to know about?" Which reply is the best response by the nurse?

"We use this drug to treat many kinds of patients, including patients with cancer. You will have periodic blood tests."

A family member of an older patient with severe dermatitis says, "I was always so careful to bathe him every day. I guess I just wasn't careful enough." Which is the best response by the nurse?

"Dermatitis is not caused by poor hygiene."

A nurse is caring for an obese patient who has been bedridden for a long time and who has a high risk for infection. Which location is best for the nurse to assess for the moist red lesions of Candida albicans?

Abdominal skinfolds

Which information is most essential for a nurse to gather when interviewing a young woman who is taking the drug isotretinoin (Accutane) for acne?

Current method of birth control

An excited mother of a teenage boy with severe acne furiously reports to the nurse, "I've told him a thousand times he should bathe more often! I've kept after him about all that junk food he eats. I jump on him when I see him squeezing his zits. I tried to get him to scrub his face three times a day!" Which statement indicates the most likely cause of the boy's acne?

Squeezing lesions

A patient who has undergone treatment for herpes simplex virus type 2 (HSV type 2) expresses relief that she is cured. Which information should the nurse include in her teaching?

HSV lies dormant and can be triggered without any sexual contact.

An 80-year-old patient comes to the emergency department with extreme pain and itching in the hip and leg and has herpetic vesicular lesions on the left hip. Which disease process should the nurse inquire about patient exposure to?

Chickenpox

A physician asks a nurse to take a smear from herpetic lesions in an older patient's hip to diagnose the disorder. Which is the most probable test that will be performed?

Tzanck test to test for viral culture

A nurse is caring for a patient with pain related to postherpetic neuralgia. Which action is the least appropriate?

Have the patient ambulate several times daily.

Which statement describes how cutaneous T-cell lymphoma differs from squamous cell and basal cell carcinomas?

Has a cause unrelated to sun exposure.

A nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia, and the fronts of both legs. Which percentage indicates how the nurse should document the burn size using the rule of nines?

37%

Which assessment by an emergency department nurse most indicates that a burn patient might be at risk for respiratory impairment?

Sooty sputum

Which assessment should a nurse be sure to frequently assess when caring for a burn patient with eschar formation around an entire arm?

Capillary refill

During the first 24 hours after a burn, fluid replacement is the treatment priority. Which assessment should alert the nurse that the fluid protocol is ineffective?

Urine output of 20 mL/hr

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?

Method of contraception used by the patient

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

Reports a history of allergic rashes

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?

Press firmly on 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?

Talk with the patient alone and ask about the bruising.

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?

Check the lips and oral mucous membranes.

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?

Cotton-tipped applicators

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next?

Assess the patient for evidence of liver disease.

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?

Incisional biopsy

During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions?

Symmetric

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?

Thickening of the skin around the ankles

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?

Petechiae on the chest and abdomen

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action?

Ask the patient about a personal or family history of type 2 diabetes.

The nurse is developing a health promotion plan for an older adult who 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)?

Erythema, Actinic keratosis

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