C HAPTER 6: T HE S KIN , H AIR , AND N AILS
MULTIPLE CHOICE
1. A patient comes to the clinic and tells the nurse that he has been confined
to his recliner chair for approximatel y 3 days with his feet down and he
asks the nurse to evaluate his feet. During the assessment, the nurse might
expect to find:
a. Pallor
b. Coolness
c. Distended veins
d. Prolonged capillary filling ti me
ANS: C
Keeping the feet in a dependent position causes venous pooling,
resulting in redness, warmth, and distended veins. Prolonged elevation
would cause pallor and coolness. Immobilization or prolonged
inactivit y would cause prolonged capillary fill ing time (see Table 12 -
1).
DIF: Cognitive Level: Appl ying (Application) REF: p. 207 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
2. A patient is especially worried about an area of skin on her feet that has
turned white. The health care provider has told her that her condition is
vitiligo. The nurse explains to her that vitiligo is:
a. Caused by an excess of melanin pigment
, b. Caused by an excess of apocrine glands in her feet
c. Caused by the complete absence of melanin pigment
d. Related to imp etigo and can be treated with an ointment
ANS: C
Vitiligo is the complete absence of melanin pigment in patchy areas of
white or light skin on the face, neck, hands, feet, body folds, and
around orifices otherwise, the depigmented skin is normal.
DIF: Cognitive Level: Appl ying (Application) REF: p. 207 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
3. A patient tells the nurse that he has noticed that one of his moles has
started to burn and bleed. When assessing his skin, the nurse pay s special
attention to the danger signs for pigmented lesions and is concerned with
which additional finding?
a. Color variation
b. Border regularit y
c. Symmetry of lesions
d. Diameter of less than 6 mm
ANS: A
Abnormal characteristics of pigmented lesions are su mmarized in the
mnemonic ABCD: asymmetry of pigmented lesion, border irregularit y,
color variation, and diameter greater than 6 mm.
, DIF: Cognitive Level: Understanding (Comprehension) REF: p. 208
MSC: Client Needs: Health Promotion and Maintenance
4. A patient comes to the clinic and states that he has noticed that his skin is
redder than normal. The nurse understands that this condition is due to
hyperemia and knows that it can be caused by:
a. Decreased amounts of bilirubin in the blood
b. Excess blood in the underl ying blood vessels
c. Decreased perfusion to the surrounding tissues
d. Excess blood in the dilated superficial capillaries
ANS: D
Erythema is an intense redness of the skin caused by excess blood
(hyperemia) in the dilated superficial capillaries.
DIF: Cognitive Level: Appl ying (Application) REF: p. 209 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
5. During a skin assessment, the nurse notices that a Mexican -American
patient has skin that is yellowish -brown; however, the skin on th e hard
and soft palate is pink and the patients scleras are not yellow. From this
finding, the nurse could probabl y rule out:
a. Pallor
b. Jaundice
c. Cyanosis
d. Iron deficiency
ANS: B
MULTIPLE CHOICE
1. A patient comes to the clinic and tells the nurse that he has been confined
to his recliner chair for approximatel y 3 days with his feet down and he
asks the nurse to evaluate his feet. During the assessment, the nurse might
expect to find:
a. Pallor
b. Coolness
c. Distended veins
d. Prolonged capillary filling ti me
ANS: C
Keeping the feet in a dependent position causes venous pooling,
resulting in redness, warmth, and distended veins. Prolonged elevation
would cause pallor and coolness. Immobilization or prolonged
inactivit y would cause prolonged capillary fill ing time (see Table 12 -
1).
DIF: Cognitive Level: Appl ying (Application) REF: p. 207 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
2. A patient is especially worried about an area of skin on her feet that has
turned white. The health care provider has told her that her condition is
vitiligo. The nurse explains to her that vitiligo is:
a. Caused by an excess of melanin pigment
, b. Caused by an excess of apocrine glands in her feet
c. Caused by the complete absence of melanin pigment
d. Related to imp etigo and can be treated with an ointment
ANS: C
Vitiligo is the complete absence of melanin pigment in patchy areas of
white or light skin on the face, neck, hands, feet, body folds, and
around orifices otherwise, the depigmented skin is normal.
DIF: Cognitive Level: Appl ying (Application) REF: p. 207 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
3. A patient tells the nurse that he has noticed that one of his moles has
started to burn and bleed. When assessing his skin, the nurse pay s special
attention to the danger signs for pigmented lesions and is concerned with
which additional finding?
a. Color variation
b. Border regularit y
c. Symmetry of lesions
d. Diameter of less than 6 mm
ANS: A
Abnormal characteristics of pigmented lesions are su mmarized in the
mnemonic ABCD: asymmetry of pigmented lesion, border irregularit y,
color variation, and diameter greater than 6 mm.
, DIF: Cognitive Level: Understanding (Comprehension) REF: p. 208
MSC: Client Needs: Health Promotion and Maintenance
4. A patient comes to the clinic and states that he has noticed that his skin is
redder than normal. The nurse understands that this condition is due to
hyperemia and knows that it can be caused by:
a. Decreased amounts of bilirubin in the blood
b. Excess blood in the underl ying blood vessels
c. Decreased perfusion to the surrounding tissues
d. Excess blood in the dilated superficial capillaries
ANS: D
Erythema is an intense redness of the skin caused by excess blood
(hyperemia) in the dilated superficial capillaries.
DIF: Cognitive Level: Appl ying (Application) REF: p. 209 MSC:
Client Needs: Physiologic Integrit y: Physiologic Adaptation
5. During a skin assessment, the nurse notices that a Mexican -American
patient has skin that is yellowish -brown; however, the skin on th e hard
and soft palate is pink and the patients scleras are not yellow. From this
finding, the nurse could probabl y rule out:
a. Pallor
b. Jaundice
c. Cyanosis
d. Iron deficiency
ANS: B
