Chapter 22: Assessment: Integumentary System
Test Bank for Lewis Medical Surgical Nursing 11th Edition by Harding
MULTIPLE CHOICE
1.A 38-year-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?
a.History of sun exposure by the patient
b.Method of birth control used by the patient
c.Length of time the patient has used fluorouracil
d.Appearance of the treated areas on the patients face ANS: B
Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2.Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?
a.Reports a history of allergic rashes
b.Scattered macular brown areas on extremities
c.Skin brown and wrinkled, skin tenting on forearm
d.Longitudinal nail bed ridges noted; sparse scalp hair ANS: A
Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment
data in the other response would be normal for an older patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3.The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
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 intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. 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: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4.When examining an older patient in the home, the home health nurse notices irregular
patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first?
a.Discourage the use of throw rugs throughout the house.
b.Ensure the patient has a pair of shoes with non-slip soles.
c.Talk with the patient alone and ask about what caused the bruising.
d.Notify the health care provider so that x-rays can be ordered as soon as possible.
ANS: C
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the
patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
5.A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?
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.
Test Bank for Lewis Medical Surgical Nursing 11th Edition by Harding
MULTIPLE CHOICE
1.A 38-year-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?
a.History of sun exposure by the patient
b.Method of birth control used by the patient
c.Length of time the patient has used fluorouracil
d.Appearance of the treated areas on the patients face ANS: B
Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2.Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?
a.Reports a history of allergic rashes
b.Scattered macular brown areas on extremities
c.Skin brown and wrinkled, skin tenting on forearm
d.Longitudinal nail bed ridges noted; sparse scalp hair ANS: A
Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment
data in the other response would be normal for an older patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3.The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
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 intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. 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: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4.When examining an older patient in the home, the home health nurse notices irregular
patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first?
a.Discourage the use of throw rugs throughout the house.
b.Ensure the patient has a pair of shoes with non-slip soles.
c.Talk with the patient alone and ask about what caused the bruising.
d.Notify the health care provider so that x-rays can be ordered as soon as possible.
ANS: C
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the
patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
5.A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?
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.
