Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

Chapter 09: Skin, Hair, and Nails Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. A patient asks the nurse if it is possible to grow new skin. What is the nurse’s most appropriate response? a. “Even if new skin growth is required, the melanocytes do not regenerate.” b. “The avascular epidermis sheds slowly and is replaced completely every 4 weeks.” c. “The outer layer of skin remains the same over the lifetime except for repairing injuries.” d. “Epidermal regeneration is impossible because it is avascular.” ANS: B Within this deepest layer of epidermis, active cell generation takes place. As cells are produced, they push up the older cells toward the skin surface. The entire process takes about 30 days. Melanocytes are not involved in regeneration. They secrete melanin, which provides pigment for the skin and hair and serves as a shield against ultraviolet radiation. The dead cells are continuously sloughed off and replaced by new cells moving up from the underlying epidermal layers. Within this deepest layer of epidermis, active cell generation takes place. DIF: Cognitive Level: Understand REF: p. 98 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a. Yellowish color in the axilla and groin b. Yellow pigmentation in the sclera c. Very pale skin on the palms d. Ashen-gray color in the oral mucous membranes ANS: B Jaundice is manifested by a yellowish color in the sclera of the eyes and palms of the hands in both light- and dark-skinned patients. Instead of the axilla and groin, assess the sclera of the eyes, fingernails, palms of hands, and oral mucosa. Pale skin may indicate anemia, but not jaundice. Yellow color of the palms indicates jaundice. Ashen-gray color may be seen in dark-skinned patients who are cyanotic. DIF: Cognitive Level: Apply REF: p. 103 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 3. How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color. NURSINGTB.COM Health Assessment for Nursing Practice 6th Edition Wilson Test Bank NU RS IN GT B.CO M ANS: C In dark-skinned patients, jaundice manifests as a yellowish-green color that can be seen most obviously in the sclera, palms of hands, and soles of feet. Ashen-gray color may be seen in dark-skinned patients who are cyanotic. Brown or purple tone is seen in dark-skinned patients with erythema. Mucous membranes do not change color from jaundice. DIF: Cognitive Level: Understand REF: p. 103 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips ANS: A Cyanosis is manifested by ashen-gray color of the oral mucous membranes and nail beds in a dark-skinned patient. An ashen-gray color of the nail beds is expected in a dark-skinned patient, rather than blue. An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient. An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient. DIF: Cognitive Level: Apply REF: p. 103 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 5. When the patient’s chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin ANS: A Purplish-red pinpoint lesions describe the appearance of petechiae. Petechiae are pinpoints, not as large as a patch. Petechiae are pinpoints, not raised as a nodule. Petechiae are pinpoints, not generalized. DIF: Cognitive Level: Understand REF: p. 103 | p. 110 | p. 115 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 6. When performing a skin assessment of an adult patient, the nurse expects what finding? a. Reddened area does not blanch when gentle pressure is applied. b. Indentation of the finger remains in the skin after palpation. c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly NURSINGTB.COM Health Assessment for Nursing Practice 6th Edition Wilson Test Bank NU RS IN GT B.CO M ANS: D Option D is an assessment of skin turgor; skin should return to its original position. Option A is an indication of a stage I pressure ulcer. Option B is a description of edema. Option C may be an indication of dry skin, systemic disease, or nutritional deficiency. DIF: Cognitive Level: Apply REF: p. 105 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Reduction of Risk Potential: System Specific Assessments 7. A nurse notices a patient’s nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes ANS: A The abnormal nail finding was koilonychia, which occurs in patients with anemia who frequently have pale conjunctiva. Jaundice is due to increased serum bilirubin, indicating liver or gallbladder disease, and does not create changes in nail structure. Ecchymosis occurs after trauma to the blood vessel resulting in bleeding under the tissue and does not cause changes in nail structure. Rashes indicate an inflammation or allergic reaction that does cause changes in the nails. DIF: Cognitive Level: Analyze REF: p. 106 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 8. A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse’s most appropriate response to this patient? a. “This is simple vellus hair and it will decrease in amount over time.” b. “Some women in your cultural group normally have dark hair on their faces.” c. “This is unusual; female hair distribution should be limited to arms, legs, and pubis.” d. “Coarse dark hair could result from hormonal changes such as from menopause.” ANS: D Coarse, dark hair on the face describes hirsutism, an increase in the growth of f