1. If a patient is not turned every 2 hours, the effect could be:
1. Occlusion of the capillary bed and tissue ischemia
2. Dilation of blood vessels and heat loss
3. Loss of collagen and skin elasticity
4. Maceration of the skin
ANS: 1 PTS: 1 DIF: Category: Integumentary
2. A potential effect of scraping the surface of the epidermis is:
1. Excessive loss of salt
2. Excessive loss of heat
3. Ischemia and tissue death
4. Increased potential for bacterial invasion
ANS: 4 PTS: 1 DIF: Category: Integumentary
3. A nurse practitioner is performing a wellness assessment on an elderly patient. Which finding during assessment of the integument is
age related?
1. Circumscribed edema and itching
2. Clubbing of the fingernails
3. Decreased skin turgor
4. Grayish skin tone
ANS: 3 PTS: 1 DIF: Category: Integumentary
4. During a routine physical examination an elderly patient asks why he has purple patches on his hands and arms. The nurse recognizes
this as senile purpura. Which response is appropriate?
1. “These are common in older persons as blood vessels weaken.”
2. “Do you fall frequently or lose your balance?”
3. “It could mean you have a bleeding disorder.”
4. “They are usually nothing to worry about.”
ANS: 1 PTS: 1 DIF: Category: Integumentary
5. The presence of senile lentigines means that the patient has:
1. Thickening of skin on the hands and feet
2. Longitudinal ridges of the nail beds
3. Clusters of benign brown spots
4. Increased facial hair
ANS: 3 PTS: 1 DIF: Category: Integumentary
6. Which piece of information alerts the nurse to the potential for photosensitivity?
,1. History of stasis dermatitis
2. Allergic to multiple allergens
3. Evidence of keloid formation
4. Lasix and Thorazine drug therapy
ANS: 4 PTS: 1 DIF: Category: Drug-related responses
7. During admission assessment the nurse notes that the patient’s color is gray. What additional areas should the nurse assess?
1. Color of the nail beds and respirations
2. Sacral edema and color of the tongue
3. Skin moisture and color of the gums
4. Oral temperature and skin turgor
ANS: 1 PTS: 1 DIF: Category: Integumentary
8. During assessment of a dark-skinned person the nurse notes that the sclerae are yellow. The most appropriate conclusion is
that:
1. This may be a normal finding for this patient
2. Liver function studies should be performed
3. The patient may have hemolytic anemia
4. The patient is jaundiced
ANS: 1 PTS: 1 DIF: Category: Integumentary
9. A fluid-filled lesion is commonly called a:
1. Fissure
2. Vesicle
3. Nodule
4. Macule
ANS: 2 PTS: 1 DIF: Category: Integumentary
10. Which documentation example describes urticaria?
1. Rough, superficial, coalesced papules over the upper extremities
2. Elevated, irregularly shaped pink wheal on the left forearm
3. Flat, nonpalpable, circumscribed lesions over the chest
4. Elevated, firm, palpable lesion on the right thigh
ANS: 2 PTS: 1 DIF: Category: Integumentary
11. What skin changes tell the most about oxygenation?
1. Asymmetrical pigmentation
2. Coarse skin texture
3. Cyanosis of the lips
4. Yellow sclerae
ANS: 3 PTS: 1 DIF: Category: Integumentary
12. In a dark-skinned patient the nurse should assess for jaundice by observing the:
,1. Hard palate
2. Gingiva
3. Sclerae
4. Palms
ANS: 1 PTS: 1 DIF: Category: Integumentary
13. To differentiate petechiae from erythema in a dark-skinned patient, the nurse should:
1. Culture the skin
2. Check to see if blanching occurs
3. Pinch the skin and watch for tenting
4. Apply cool compresses to the area and observe the response
ANS: 2 PTS: 1 DIF: Category: Integumentary
14. Which description refers to the “configuration” of the lesion being described?
1. 1-cm vesicle on the lower lip
2. Solid, well-demarcated papule
3. Asymmetrical, brown lesion on the left ear
4. Multiple small pustules over the
forehead ANS: 2
1. A patient with acute myelocytic leukemia received chemotherapy and steroids 2 weeks ago. Which is an assessment
priority?
1. Hands and feet, for beefy red papules associated with psoriasis
2. Extremities, for manifestations of atopic dermatitis
3. Skin, for signs and symptoms of stasis dermatitis
4. Oral mucosa, for evidence of thrush
ANS: 4 PTS: 1 DIF: Category: Integumentary
2. For the patient who has candidiasis of the mouth, the nurse expects the physician to order:
1. Acyclovir
2. Mycostatin
3. Griseofulvin
4. Capsaicin cream
ANS: 2 PTS: 1 DIF: Category: Drug-related responses
3. An appropriate goal for the person who has tinea pedis is that the patient will:
1. Verbalize appropriate foot hygiene
2. Verbalize the rationale for washing bed linen daily
3. List important principles for cleaning the groin area
4. Identify reasons for shampooing the scalp twice per
week ANS: 1
4. During his summer vacation, a 12-year-old boy presents to the health clinic with small vesicles covering his face and neck.
The nurse notes a honey-colored crust adhered to the skin. The most likely cause of the problem is:
, 1. Herpes simplex
2. Erysipelas
3. Folliculitis
4. Impetigo
ANS: 4 PTS: 1 DIF: Category: Integumentary
5. Which is considered a risk factor for furuncles and carbuncles?
1. Family history of skin infections
2. Work that involves handling food
3. Poorly controlled diabetes mellitus
4. Walking barefoot around swimming pools
ANS: 3 PTS: 1 DIF: Category: Integumentary
6. Collaborative care management of the individual with a furuncle includes:
1. Cold packs to decrease pain
2. Laser surgery to remove the furuncle
3. Application of Burrow’s solution to reduce the boil
4. Warm, moist dressings to help bring the boil to a head
ANS: 4 PTS: 1 DIF: Category: Integumentary
7. A patient is admitted with shingles. An appropriate conclusion is that the patient:
1. Is older than 65 years
2. Is immunocompromised
3. Never had chickenpox as a child
4. Poses a threat to people who have never had chickenpox
ANS: 4 PTS: 1 DIF: Category: Integumentary
8. A patient has herpes zoster involving the nerve pathways on the right side of the body. The nurse can expect lesions to:
1. Cross the midline of the body and appear bilaterally
2. Form a line on the right side of the body
3. Be scattered over the torso
4. Center around the neck
ANS: 2 PTS: 1 DIF: Category: Integumentary
9. Which group of symptoms does the nurse expect a patient with herpes zoster to exhibit?
1. Fever and malaise followed by eruption of vesicles
2. Severe pain followed by a macular rash
3. Enlargement of superficial blood vessels
4. Petechiae over the lower extremities
ANS: 1 PTS: 1 DIF: Category: Integumentary
10. Which collaborative treatment choices are most effective as pain-reduction measures for the person with herpes zoster?
1. Intravenous acyclovir and steroids
1. Occlusion of the capillary bed and tissue ischemia
2. Dilation of blood vessels and heat loss
3. Loss of collagen and skin elasticity
4. Maceration of the skin
ANS: 1 PTS: 1 DIF: Category: Integumentary
2. A potential effect of scraping the surface of the epidermis is:
1. Excessive loss of salt
2. Excessive loss of heat
3. Ischemia and tissue death
4. Increased potential for bacterial invasion
ANS: 4 PTS: 1 DIF: Category: Integumentary
3. A nurse practitioner is performing a wellness assessment on an elderly patient. Which finding during assessment of the integument is
age related?
1. Circumscribed edema and itching
2. Clubbing of the fingernails
3. Decreased skin turgor
4. Grayish skin tone
ANS: 3 PTS: 1 DIF: Category: Integumentary
4. During a routine physical examination an elderly patient asks why he has purple patches on his hands and arms. The nurse recognizes
this as senile purpura. Which response is appropriate?
1. “These are common in older persons as blood vessels weaken.”
2. “Do you fall frequently or lose your balance?”
3. “It could mean you have a bleeding disorder.”
4. “They are usually nothing to worry about.”
ANS: 1 PTS: 1 DIF: Category: Integumentary
5. The presence of senile lentigines means that the patient has:
1. Thickening of skin on the hands and feet
2. Longitudinal ridges of the nail beds
3. Clusters of benign brown spots
4. Increased facial hair
ANS: 3 PTS: 1 DIF: Category: Integumentary
6. Which piece of information alerts the nurse to the potential for photosensitivity?
,1. History of stasis dermatitis
2. Allergic to multiple allergens
3. Evidence of keloid formation
4. Lasix and Thorazine drug therapy
ANS: 4 PTS: 1 DIF: Category: Drug-related responses
7. During admission assessment the nurse notes that the patient’s color is gray. What additional areas should the nurse assess?
1. Color of the nail beds and respirations
2. Sacral edema and color of the tongue
3. Skin moisture and color of the gums
4. Oral temperature and skin turgor
ANS: 1 PTS: 1 DIF: Category: Integumentary
8. During assessment of a dark-skinned person the nurse notes that the sclerae are yellow. The most appropriate conclusion is
that:
1. This may be a normal finding for this patient
2. Liver function studies should be performed
3. The patient may have hemolytic anemia
4. The patient is jaundiced
ANS: 1 PTS: 1 DIF: Category: Integumentary
9. A fluid-filled lesion is commonly called a:
1. Fissure
2. Vesicle
3. Nodule
4. Macule
ANS: 2 PTS: 1 DIF: Category: Integumentary
10. Which documentation example describes urticaria?
1. Rough, superficial, coalesced papules over the upper extremities
2. Elevated, irregularly shaped pink wheal on the left forearm
3. Flat, nonpalpable, circumscribed lesions over the chest
4. Elevated, firm, palpable lesion on the right thigh
ANS: 2 PTS: 1 DIF: Category: Integumentary
11. What skin changes tell the most about oxygenation?
1. Asymmetrical pigmentation
2. Coarse skin texture
3. Cyanosis of the lips
4. Yellow sclerae
ANS: 3 PTS: 1 DIF: Category: Integumentary
12. In a dark-skinned patient the nurse should assess for jaundice by observing the:
,1. Hard palate
2. Gingiva
3. Sclerae
4. Palms
ANS: 1 PTS: 1 DIF: Category: Integumentary
13. To differentiate petechiae from erythema in a dark-skinned patient, the nurse should:
1. Culture the skin
2. Check to see if blanching occurs
3. Pinch the skin and watch for tenting
4. Apply cool compresses to the area and observe the response
ANS: 2 PTS: 1 DIF: Category: Integumentary
14. Which description refers to the “configuration” of the lesion being described?
1. 1-cm vesicle on the lower lip
2. Solid, well-demarcated papule
3. Asymmetrical, brown lesion on the left ear
4. Multiple small pustules over the
forehead ANS: 2
1. A patient with acute myelocytic leukemia received chemotherapy and steroids 2 weeks ago. Which is an assessment
priority?
1. Hands and feet, for beefy red papules associated with psoriasis
2. Extremities, for manifestations of atopic dermatitis
3. Skin, for signs and symptoms of stasis dermatitis
4. Oral mucosa, for evidence of thrush
ANS: 4 PTS: 1 DIF: Category: Integumentary
2. For the patient who has candidiasis of the mouth, the nurse expects the physician to order:
1. Acyclovir
2. Mycostatin
3. Griseofulvin
4. Capsaicin cream
ANS: 2 PTS: 1 DIF: Category: Drug-related responses
3. An appropriate goal for the person who has tinea pedis is that the patient will:
1. Verbalize appropriate foot hygiene
2. Verbalize the rationale for washing bed linen daily
3. List important principles for cleaning the groin area
4. Identify reasons for shampooing the scalp twice per
week ANS: 1
4. During his summer vacation, a 12-year-old boy presents to the health clinic with small vesicles covering his face and neck.
The nurse notes a honey-colored crust adhered to the skin. The most likely cause of the problem is:
, 1. Herpes simplex
2. Erysipelas
3. Folliculitis
4. Impetigo
ANS: 4 PTS: 1 DIF: Category: Integumentary
5. Which is considered a risk factor for furuncles and carbuncles?
1. Family history of skin infections
2. Work that involves handling food
3. Poorly controlled diabetes mellitus
4. Walking barefoot around swimming pools
ANS: 3 PTS: 1 DIF: Category: Integumentary
6. Collaborative care management of the individual with a furuncle includes:
1. Cold packs to decrease pain
2. Laser surgery to remove the furuncle
3. Application of Burrow’s solution to reduce the boil
4. Warm, moist dressings to help bring the boil to a head
ANS: 4 PTS: 1 DIF: Category: Integumentary
7. A patient is admitted with shingles. An appropriate conclusion is that the patient:
1. Is older than 65 years
2. Is immunocompromised
3. Never had chickenpox as a child
4. Poses a threat to people who have never had chickenpox
ANS: 4 PTS: 1 DIF: Category: Integumentary
8. A patient has herpes zoster involving the nerve pathways on the right side of the body. The nurse can expect lesions to:
1. Cross the midline of the body and appear bilaterally
2. Form a line on the right side of the body
3. Be scattered over the torso
4. Center around the neck
ANS: 2 PTS: 1 DIF: Category: Integumentary
9. Which group of symptoms does the nurse expect a patient with herpes zoster to exhibit?
1. Fever and malaise followed by eruption of vesicles
2. Severe pain followed by a macular rash
3. Enlargement of superficial blood vessels
4. Petechiae over the lower extremities
ANS: 1 PTS: 1 DIF: Category: Integumentary
10. Which collaborative treatment choices are most effective as pain-reduction measures for the person with herpes zoster?
1. Intravenous acyclovir and steroids
