NSG 4067: INTEGUMENTARY FUNCTION
1. A client is unresponsive, the skin is usually dry, confined to bed, with limited mobility and
contractures, and the nutrition is less than adequate. Using the Braden score, which score will be
assigned to this client's risk for pressure ulcers?
A) 8, very high risk
B) 8, at risk
C) 18, high risk
D) 18, moderate risk
Ans: A
Feedback:
The nurse uses the Braden score to determine the plan of care. The lower the Braden score, the
greater the risk. Scores of 9 or less are considered to be at very high risk, and additional pressure
relieving surface and treatment of nutrition are important for this client.
2. A nurse teaches older adults about skin care and aging. Which of the following would be
appropriate to include in this teaching? (Select all that apply.)
A) Avoid sunscreens with a sun protection factor (SPF) higher than 14.
B) Gently apply rubbing alcohol to keratosis growths to remove them.
C) Include adequate amounts of fluid and vitamins in the daily diet.
D) Use firm rubbing motions when drying your skin.
E) Use emollient moisturizing lotions after bathing.
F) When bathing or showering, use a mild, unscented soap.
Ans: C, E, F
Feedback:
Older adults need an adequate intake of calories, nutrients, and hydration. Older adults should
use a gentle, patting motion when drying their skin ensuring dry skin between toes. Older adults
need to use a sunscreen with an SPF of 15 or higher even on overcast days and apply the
emollient moisturizing lotion after bathing (not oils during bathing).
3. The nurse assesses the fluid volume status of a 72-year-old client who takes Lasix
(furosemide) and Pacerone (amiodarone). Which of the following is the most reliable method for
assessing this client's skin turgor?
A) Ask the client to open the mouth and examine the oral mucous membranes for dryness.
B) Examine the skin on the lower legs and look for dry, scaly, or rough skin.
C) Gently pinch the skin on the abdomen to see how long it takes to return to normal.
, D) Squeeze the skin on back of hand to see if it remains pinched or is slow to return to
normal.
Ans: C
Feedback:
Skin turgor should be checked over protected areas, such as the sternum or abdomen. The use of
diuretics can exacerbate xerosis that older adults may have. Diuretics and amiodarone increase
the risk for photosensitivity.
4. A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe
touched the skin. Which of the following should the nurse document?
A) 2-mm stage II pressure ulcer
B) Stage III pressure ulcer on great toe
C) 2-mm skin tear with red wound bed
D) Red ulcer on the great toe 2 mm in size
Ans: A
Feedback:
The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging
should be used to document all pressure ulcers. Wound documentation should also include size
of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough.
5. Which of the following functional consequences of skin changes will impact the nursing care
of older adults?
A) Older adults have an increased incidence of moles requiring intervention.
B) There is a decreased incidence of skin cancer in older adults because of an increase in
melanocytes.
C) In older adults, tactile sensitivity increases and there is an intense response to cutaneous
stimulation.
D) Collagen changes interfere with tensile strength of older adults' skin, causing the skin to
be less resilient.
Ans: D
Feedback:
There is less tensile strength of the skin because of collagen changes, which predisposes the
older adult to abrasive and tearing skin damage. There is a decreased incidence of moles after 40
years of age. There is an increased incidence of skin cancer in older adults, and decreased
1. A client is unresponsive, the skin is usually dry, confined to bed, with limited mobility and
contractures, and the nutrition is less than adequate. Using the Braden score, which score will be
assigned to this client's risk for pressure ulcers?
A) 8, very high risk
B) 8, at risk
C) 18, high risk
D) 18, moderate risk
Ans: A
Feedback:
The nurse uses the Braden score to determine the plan of care. The lower the Braden score, the
greater the risk. Scores of 9 or less are considered to be at very high risk, and additional pressure
relieving surface and treatment of nutrition are important for this client.
2. A nurse teaches older adults about skin care and aging. Which of the following would be
appropriate to include in this teaching? (Select all that apply.)
A) Avoid sunscreens with a sun protection factor (SPF) higher than 14.
B) Gently apply rubbing alcohol to keratosis growths to remove them.
C) Include adequate amounts of fluid and vitamins in the daily diet.
D) Use firm rubbing motions when drying your skin.
E) Use emollient moisturizing lotions after bathing.
F) When bathing or showering, use a mild, unscented soap.
Ans: C, E, F
Feedback:
Older adults need an adequate intake of calories, nutrients, and hydration. Older adults should
use a gentle, patting motion when drying their skin ensuring dry skin between toes. Older adults
need to use a sunscreen with an SPF of 15 or higher even on overcast days and apply the
emollient moisturizing lotion after bathing (not oils during bathing).
3. The nurse assesses the fluid volume status of a 72-year-old client who takes Lasix
(furosemide) and Pacerone (amiodarone). Which of the following is the most reliable method for
assessing this client's skin turgor?
A) Ask the client to open the mouth and examine the oral mucous membranes for dryness.
B) Examine the skin on the lower legs and look for dry, scaly, or rough skin.
C) Gently pinch the skin on the abdomen to see how long it takes to return to normal.
, D) Squeeze the skin on back of hand to see if it remains pinched or is slow to return to
normal.
Ans: C
Feedback:
Skin turgor should be checked over protected areas, such as the sternum or abdomen. The use of
diuretics can exacerbate xerosis that older adults may have. Diuretics and amiodarone increase
the risk for photosensitivity.
4. A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe
touched the skin. Which of the following should the nurse document?
A) 2-mm stage II pressure ulcer
B) Stage III pressure ulcer on great toe
C) 2-mm skin tear with red wound bed
D) Red ulcer on the great toe 2 mm in size
Ans: A
Feedback:
The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging
should be used to document all pressure ulcers. Wound documentation should also include size
of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough.
5. Which of the following functional consequences of skin changes will impact the nursing care
of older adults?
A) Older adults have an increased incidence of moles requiring intervention.
B) There is a decreased incidence of skin cancer in older adults because of an increase in
melanocytes.
C) In older adults, tactile sensitivity increases and there is an intense response to cutaneous
stimulation.
D) Collagen changes interfere with tensile strength of older adults' skin, causing the skin to
be less resilient.
Ans: D
Feedback:
There is less tensile strength of the skin because of collagen changes, which predisposes the
older adult to abrasive and tearing skin damage. There is a decreased incidence of moles after 40
years of age. There is an increased incidence of skin cancer in older adults, and decreased
