Chapter 25: Nursing Assessment: Integumentary System:
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient who has a circular, flat, reddened lesion about 5 cm
in diameter on his ankle. Which of the following actions would the nurse implement to
determine whether the lesion is related to blood vessel dilation?
A. Elevate the patient's 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.
Answer: B
Explanation: 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.
2. The nurse is conducting a health history with a patient and the nurse discovers that
the patient works as a roofer. The nurse will plan to teach the patient about how to self-
assess for clinical manifestations of which of the following integument conditions?
(Select all that apply.)
A. Alopecia
B. Intertrigo
C. Wrinkling
D. Erythema
E. Actinic keratosis
Answer: C, D, E
Explanation: A patient who works as a roofer is at risk for integumentary lesions caused by
sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are
not associated with excessive sun exposure.
3. The nurse is preparing for a teaching session with older-adult patients. Which of the
following changes is an age-related change in the hair?
A. Increased melanocytes
B. Decreased oils
C. Increased density
D. Increased estrogen
,Answer: B
Explanation: Age-related changes to the hair include decreased oils, density, estrogen, and
melanocytes.
4. The nurse is caring for a patient who is dark-skinned and has been admitted to the
hospital in severe respiratory distress. Which of the following actions should the nurse
implement to determine whether the patient is cyanotic?
A. Assess the skin colour 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.
Answer: C
Explanation: Cyanosis in dark-skinned individuals is more easily seen in the mucous
membranes. Earlobe colour may change in light-skinned individuals, but this change in skin
colour 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 colour.
5. A patient asks the nurse why a potassium hydroxide test needs to be done. The
nurse's response is based upon the knowledge that which of the following is the purpose
of this test?
A. Examine a lesion via a biopsy.
B. Obtain fluids from vesicles for assessment.
C. Assess for fungal infection.
D. Scrap exudate from a lesion for microscopic examination.
Answer: C
Explanation: A potassium hydroxide test is done to examine hair, nails, or scales for
superficial fungal infection. Scraping exudate from a lesion for examination is used with
mineral oil slides. A Tzanck test is used when fluid is obtained from vesicles for assessment.
6. The nurse is caring for a patient who has several angiomas on their legs. Which of the
following actions should the nurse take next?
A. Assess the patient for evidence of liver disease.
B. Discuss the adverse effects of sun exposure on the skin.
C. Educate the patient about possible skin changes with aging.
D. Suggest that the patient make an appointment with a dermatologist.
Answer: A
,Explanation: Angiomas are a common occurrence as patient's age, but they may occur with
systemic problems such as liver disease. The patient may want to see a dermatologist to have
the angiomas removed, but this is not the initial action by the nurse. The nurse may need to
educate the patient about the effects of aging on the skin and about the effects of sun
exposure, but the initial action should be further assessment.
7. The nurse is caring for a patient in the dermatology clinic who is scheduled for
removal of a 15-mm multicoloured and irregular mole from the upper back. Which of
the following biopsies would the nurse teach to this patient?
A. Shave
B. Punch
C. Incisional
D. Excisional
Answer: C
Explanation: An incisional biopsy would remove the entire mole and the tissue borders. The
appearance of the mole indicates that it may be malignant; a shave biopsy would not remove
the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies
are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.
8. The nurse is conducting an assessment of the patient's skin and observes a ring of
small, raised, discrete lesions filled with serous fluid on the patient's right temple.
Which of the following descriptions would the nurse use when documenting the lesions?
A. Grouped
B. Confluent
C. Zosteriform
D. Generalized
Answer: A
Explanation: The description of the lesions indicates that they are grouped. The other terms
are inconsistent with the description of the lesions.
9. The nurse is caring for a patient who reports persistent itching of the ankles and
cannot keep from continuously scratching them. The nurse will plan to implement
interventions to decrease the risk for which of the following conditions?
A. Skin atrophy
B. Lichenification
C. Skin varicosity
D. Keloid formation
, Answer: B
Explanation: Lichenification is likely to occur in areas where the patient scratches the skin
frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.
10. Which assessment information documented in a patient's 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"
Answer: D
Explanation: 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.
11. The nurse is admitting an older-adult patient to an assisted-living facility and notes
abnormalities on the skin. Which of the following abnormalities is the priority to discuss
immediately with the health care provider?
A. Several dry, scaly patches on the face
B. Numerous varicosities noted on both legs
C. Dilation of small blood vessels on the face
D. Petechiae present on the chest and abdomen
Answer: D
Explanation: Petechiae are caused by pinpoint hemorrhages and are associated with
inflammation, marked dilation, blood vessel trauma, and blood dyscrasia that results in
bleeding tendencies (e.g., thrombocytopenia). The nurse should contact the patient's health
care provider about this finding for further diagnostic follow-up. The other skin changes are
associated with aging. Although the other changes also will require ongoing monitoring or
intervention by the nurse, they do not indicate a need for urgent action.
12. The nurse is conducting a health assessment on an older-adult patient and is
assessing the patient's nails. Which of the following assessments are age-related
changes? (Select all that apply.)
A. Longitudinal ridging
B. Decreased keratin
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient who has a circular, flat, reddened lesion about 5 cm
in diameter on his ankle. Which of the following actions would the nurse implement to
determine whether the lesion is related to blood vessel dilation?
A. Elevate the patient's 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.
Answer: B
Explanation: 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.
2. The nurse is conducting a health history with a patient and the nurse discovers that
the patient works as a roofer. The nurse will plan to teach the patient about how to self-
assess for clinical manifestations of which of the following integument conditions?
(Select all that apply.)
A. Alopecia
B. Intertrigo
C. Wrinkling
D. Erythema
E. Actinic keratosis
Answer: C, D, E
Explanation: A patient who works as a roofer is at risk for integumentary lesions caused by
sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are
not associated with excessive sun exposure.
3. The nurse is preparing for a teaching session with older-adult patients. Which of the
following changes is an age-related change in the hair?
A. Increased melanocytes
B. Decreased oils
C. Increased density
D. Increased estrogen
,Answer: B
Explanation: Age-related changes to the hair include decreased oils, density, estrogen, and
melanocytes.
4. The nurse is caring for a patient who is dark-skinned and has been admitted to the
hospital in severe respiratory distress. Which of the following actions should the nurse
implement to determine whether the patient is cyanotic?
A. Assess the skin colour 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.
Answer: C
Explanation: Cyanosis in dark-skinned individuals is more easily seen in the mucous
membranes. Earlobe colour may change in light-skinned individuals, but this change in skin
colour 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 colour.
5. A patient asks the nurse why a potassium hydroxide test needs to be done. The
nurse's response is based upon the knowledge that which of the following is the purpose
of this test?
A. Examine a lesion via a biopsy.
B. Obtain fluids from vesicles for assessment.
C. Assess for fungal infection.
D. Scrap exudate from a lesion for microscopic examination.
Answer: C
Explanation: A potassium hydroxide test is done to examine hair, nails, or scales for
superficial fungal infection. Scraping exudate from a lesion for examination is used with
mineral oil slides. A Tzanck test is used when fluid is obtained from vesicles for assessment.
6. The nurse is caring for a patient who has several angiomas on their legs. Which of the
following actions should the nurse take next?
A. Assess the patient for evidence of liver disease.
B. Discuss the adverse effects of sun exposure on the skin.
C. Educate the patient about possible skin changes with aging.
D. Suggest that the patient make an appointment with a dermatologist.
Answer: A
,Explanation: Angiomas are a common occurrence as patient's age, but they may occur with
systemic problems such as liver disease. The patient may want to see a dermatologist to have
the angiomas removed, but this is not the initial action by the nurse. The nurse may need to
educate the patient about the effects of aging on the skin and about the effects of sun
exposure, but the initial action should be further assessment.
7. The nurse is caring for a patient in the dermatology clinic who is scheduled for
removal of a 15-mm multicoloured and irregular mole from the upper back. Which of
the following biopsies would the nurse teach to this patient?
A. Shave
B. Punch
C. Incisional
D. Excisional
Answer: C
Explanation: An incisional biopsy would remove the entire mole and the tissue borders. The
appearance of the mole indicates that it may be malignant; a shave biopsy would not remove
the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies
are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.
8. The nurse is conducting an assessment of the patient's skin and observes a ring of
small, raised, discrete lesions filled with serous fluid on the patient's right temple.
Which of the following descriptions would the nurse use when documenting the lesions?
A. Grouped
B. Confluent
C. Zosteriform
D. Generalized
Answer: A
Explanation: The description of the lesions indicates that they are grouped. The other terms
are inconsistent with the description of the lesions.
9. The nurse is caring for a patient who reports persistent itching of the ankles and
cannot keep from continuously scratching them. The nurse will plan to implement
interventions to decrease the risk for which of the following conditions?
A. Skin atrophy
B. Lichenification
C. Skin varicosity
D. Keloid formation
, Answer: B
Explanation: Lichenification is likely to occur in areas where the patient scratches the skin
frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.
10. Which assessment information documented in a patient's 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"
Answer: D
Explanation: 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.
11. The nurse is admitting an older-adult patient to an assisted-living facility and notes
abnormalities on the skin. Which of the following abnormalities is the priority to discuss
immediately with the health care provider?
A. Several dry, scaly patches on the face
B. Numerous varicosities noted on both legs
C. Dilation of small blood vessels on the face
D. Petechiae present on the chest and abdomen
Answer: D
Explanation: Petechiae are caused by pinpoint hemorrhages and are associated with
inflammation, marked dilation, blood vessel trauma, and blood dyscrasia that results in
bleeding tendencies (e.g., thrombocytopenia). The nurse should contact the patient's health
care provider about this finding for further diagnostic follow-up. The other skin changes are
associated with aging. Although the other changes also will require ongoing monitoring or
intervention by the nurse, they do not indicate a need for urgent action.
12. The nurse is conducting a health assessment on an older-adult patient and is
assessing the patient's nails. Which of the following assessments are age-related
changes? (Select all that apply.)
A. Longitudinal ridging
B. Decreased keratin
