Med Surg, Integumentary System
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 patients 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.
2. Which assessment information documented in a patients 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.
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 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 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.
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 patients 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.
5. A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine
whether the patient is cyanotic, the nurse will
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.
6. The nurse is preparing to obtain a culture from a patient who has a possible fungal infection in the
groin area. Which action is appropriate?
a.
Apply a topical anesthetic before obtaining the culture.
b.
Use sterile gloves to squeeze the lesion and obtain exudate.
c.
Swab the infected area with a sterile cotton-tipped applicator.
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 patients 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.
2. Which assessment information documented in a patients 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.
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 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 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.
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 patients 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.
5. A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine
whether the patient is cyanotic, the nurse will
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.
6. The nurse is preparing to obtain a culture from a patient who has a possible fungal infection in the
groin area. Which action is appropriate?
a.
Apply a topical anesthetic before obtaining the culture.
b.
Use sterile gloves to squeeze the lesion and obtain exudate.
c.
Swab the infected area with a sterile cotton-tipped applicator.
