Chapter 48: Assessment of the Integumentary System Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 48: Assessment of the Integumentary System

MULTIPLE CHOICE

1. When the client taking chlorpromazine (Thorazine), phenytoin (Dilantin), penicillin, and a multivitamin complains of a sunburn-like rash on the face and arms, the nurse would suspect the cause to be the

a.

dilantin.

b.

multivitamin.

c.

penicillin.

d.

tetracycline.

ANS: D

Phenothiazines, tetracycline, diuretics, and sulfonamides are photosensitizing drugs that can cause a sunburn-like rash in areas of sun exposure.

DIF: Comprehension/Understanding REF: p. 1189 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

2. On examination of a client, the nurse notes elevated, solid, brown skin lesions that are each 0.5 cm in size. The nurse would describe these lesions as

a.

papules.

b.

plaques.

c.

macules.

d.

nodules.

ANS: A

A papule is an elevated solid lesion less than 1 cm in size and varying in color.

DIF: Knowledge/Remembering REF: pp. 1191-1192

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

3. A client has elevated lesions that contain serous fluid. The nurse would document these as

a.

nodules.

b.

pustules.

c.

vesicles.

d.

wheals.

ANS: C

A vesicle is an elevated, sharply defined lesion containing serous fluid (e.g., blister, chickenpox, herpes simplex). Vesicles are usually less than 1 cm in size.

DIF: Application/Applying REF: pp. 1191-1192

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

4. The nurse caring for a child with impetigo notes that some of the lesions on the childs skin appear elevated and contain purulent material. Secondary lesions are also present and are honey colored. The nurse would document these lesions as

a.

cysts and bullae.

b.

nodules and scales.

c.

pustules and crusts.

d.

vesicles and excoriations.

ANS: C

A pustule is an elevated lesion less than 1 cm in size containing purulent material. A crust is dried sebum, serum, blood, or pus on the skin surface (e.g., impetigo).

DIF: Application/Applying REF: pp. 1191-1192

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

5. The nurse observes crusty brown lesions covering a clients back. To assist in identifying a possible cause, the most helpful question the nurse would ask the client is

a.

Have you recently changed laundry detergents?

b.

How much does the rash itch?

c.

What did the rash look like when you first noticed it?

d.

What did you eat last night?

ANS: C

Frequently the health care provider will not see a primary lesion and must depend on the client to describe the initial appearance of the lesion. A crust is a secondary lesion.

DIF: Application/Applying REF: p. 1190 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

6. When the nurse lifts the clients foot to clean it during bathing, the nurse notices that it is cool to the touch. The nurses most appropriate initial action would be to

a.

compare the temperature of the foot with the clients other foot.

b.

document the finding on the clients chart.

c.

inspect hair distribution on the lower half of the leg.

d.

Place the extremity under a blanket and continue the bath.

ANS: A

Areas of hypothermia or hyperthermia are compared with the same side on the opposite extremity.

DIF: Application/Applying REF: p. 1194 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

7. After tape is applied for skin patch testing, the nurse would include in the clients instructions to return to the clinic for tape removal and initial reading in

a.

24 hours.

b.

48 hours.

c.

3 days.

d.

7 days.

ANS: B

The tape must be worn for 48 hours without disturbing the patches; then the tape is removed. Interpretations are made at 48, 72, and 96 hours and sometimes at 1 week.

DIF: Application/Applying REF: p. 1197 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

8. After a clients surgical excisional biopsy, the nurse would apply

a.

antibiotic ointment and a dry dressing.

b.

Band-Aids only.

c.

hydrocolloid dressing only.

d.

petrolatum gauze and paper tape.

ANS: A

After excisional biopsy, the nurse should cover the major biopsy sites with antibiotic ointment and a clean bandage or dry dressing unless ordered otherwise.

DIF: Application/Applying REF: p. 1197 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

9. The nurse would explain to a client that an allergy differs from an irritation in that an allergy

a.

affects the skin and mucous membranes only.

b.

is an immune response.

c.

is inconsistent.

d.

can be totally desensitized.

ANS: B

Allergies are consistent immune responses that can act on skin, mucous membranes, organs, and vessels.

DIF: Comprehension/Understanding REF: pp. 1187-1188

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

10. The nurse would record the presence of a lichenification as a

a.

complicated lesion.

b.

primary lesion.

c.

secondary lesion.

d.

simple lesion.

ANS: C

There are nine secondary lesions: scale, crust, erosion, deep ulcer, scar, lichenification, excoriation, fissure, and atrophy.

DIF: Comprehension/Understanding REF: p. 1190 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

11. In a highly pigmented client, the nurse would best assess for erythema by

a.

follicular accentuation.

b.

induration.

c.

reddening of the skin.

d.

striation.

ANS: A

Inflammatory changes are difficult to assess in dark-skinned clients, but follicular accentuation is clearly visible as a manifestation of erythema.

DIF: Application/Applying REF: p. 1192 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. A client is undergoing a lengthy series of treatments for a skin disorder. The best method of documenting the clients experience with the treatments is for the nurse to

a.

document the lesions clearly at each visit using proper terminology.

b.

draw the distribution and characteristics of the lesions occasionally.

c.

have the client record ongoing changes and include them in the record.

d.

photograph the lesions at each clinic visit and use them for comparison.

ANS: D

Clients often need a series of treatments and lesions often need to be observed over time. Photographing lesions is an excellent way to document their changes over time. Documenting clearly using appropriate terminology is always a correct thing to do; however, photographing is more specific to skin lesions and more accurate.

DIF: Application/Applying REF: p. 1194 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Documentation

MULTIPLE RESPONSE

1. The nurse would explain to a client that examples of primary skin lesions include (Select all that apply)

a.

cysts.

b.

macules.

c.

scales.

d.

plaque.

e.

pustules.

f.

wheals.

ANS: A, B, D, E, F

There are 10 primary types of lesions: macule, papule, plaque, nodule, tumor, wheal, vesicle, bulla, cyst, and pustule. Scales are secondary lesions.

DIF: Comprehension/Understanding REF: p. 1190 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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