Chapter 11 - Skin, Hair, and Nails

Question 1

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is ______.

a. Highly vascular.
b. Thick and tough.
c. Thin and nonstratified.
d. Replaced every 4 weeks.

Answer 1

d. Replaced every 4 weeks.

Rationale: The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several
zones.

Question 2

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:

a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.

Answer 2

d. Contains sensory receptors.

Rationale: The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch,
and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced
every 4 weeks.

Question 3

The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesn’t have an odor. The nurse knows that this condition could be related to:

a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.

Answer 3

Eccrine

Rationale: The eccrine glands are coiled tubules that directly open onto the skin surface and produce a
dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patients statement is not related to disorders of the stratum corneum or the
stratum germinativum.

Question 4

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?

a. Subcutaneous fat deposits are high in the newborn.
b. Sebaceous glands are overproductive in the newborn.
c. The newborns skin is more permeable than that of the adult.
d. The amount of vernix caseosa dramatically rises in the newborn.

Answer 4

c. The newborns skin is more permeable than that of the adult.

Rationale: The newborns skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

Question 5

The nurse is bathing an 80 year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat

Answer 5

d. An increased loss of elastin and a decrease in subcutaneous fat

Rationale: An accumulation of factors place the aging person at risk for skin disease and breakdown: the
thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

Question 6

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

a. Metrocytes.
b. Fungacytes.
c. Phagocytes.
d. Melanocytes.

Answer 6

Melanocytes.

Rationale: In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine.

Question 7

7. During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
   a. Xerosis.
   b. Pruritus.
   c. Alopecia.
   d. Seborrhea.

Answer 7

Xerosis.

Rationale: Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

Question 8

A 22 year-old woman comes to the clinic because of severe sunburn and states, I was out in the sun for just a couple of minutes. The nurse begins a medication review with her, paying special attention to which medication class?

a. Nonsteroidal anti-inflammatory drugs for pain
b. Tetracyclines for acne
c. Proton pump inhibitors for heartburn
d. Thyroid replacement hormone for hypothyroidism

Answer 8

b. Tetracyclines for acne

Rationale: Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Question 9

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?

a. Increased possibility of bruising
b. Skin sensitivity as a result of exposure to salt water
c. Lack of availability of glucose-monitoring supplies
d. Importance of sunscreen and avoiding direct sunlight

Answer 9

d. Importance of sunscreen and avoiding direct sunlight

Rationale: Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides,
thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Question 10

A 13 year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:

a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.

Answer 10

c. Is caused by increased sebum production.

Rationale: Approximately 90% of males and 80% of females will develop acne; causes are increased sebum
production and epithelial cells that do not desquamate normally.

Question 11

A 75 year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:

a. The woman could be at increased risk for infection and lesions because of her chronic disease.
b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding.
c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury
d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach

Answer 11

a. The woman could be at increased risk for infection and lesions because of her chronic disease.

Rationale: A personal history of diabetes and peripheral vascular disease increases a persons risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

Question 12

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a persons:

a. Support systems.
b. Circulatory status.
c. Socioeconomic status.
d. Psychological wellness.

Answer 12

b. Circulatory status.

Rationale: The skin holds information about the body’s circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.

Question 13

A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:

a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.

Answer 13

c. Peripheral vasoconstriction.

Rationale: A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness.

Question 14

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 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 time

Answer 14

c. Distended veins

Rationale: 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 inactivity would cause prolonged capillary filling time.

Question 15

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 impetigo and can be treated with an ointment

Answer 15

c. Caused by the complete absence of melanin pigment

Rationale: 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.

Question 16

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 pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

a. Color variation
b. Border regularity
c. Symmetry of lesions
d. Diameter of less than 6 mm

Answer 16

a. Color variation

Rationale: Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

Question 17

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 underlying blood vessels.
c. Decreased perfusion to the surrounding tissues.
d. Excess blood in the dilated superficial capillaries.

Answer 17

d. Excess blood in the dilated superficial capillaries.

Rationale: Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated
superficial capillaries.

Question 18

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patients scleras are not yellow. From this finding, the nurse could probably rule out:

a. Pallor
b. Jaundice
c. Cyanosis
d. Iron deficiency

Answer 18

b. Jaundice

Rationale: Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

Question 19

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patients skin?

a. Ruddy blue.
b. Generalized pallor.
c. Ashen, gray, or dull.
d. Patchy areas of pallor.

Answer 19

c. Ashen, gray, or dull.

Rationale: Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull.

Question 20

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?

a. Smooth mucous membranes and lips.
b. Dry mucous membranes and cracked lips.
c. Pale mucous membranes.
d. White patches on the mucous membranes.

Answer 20

b. Dry mucous membranes and cracked lips.

Rationale: With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

Question 21

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:

a. Anasarca.
b. Scleroderma.
c. Senile angiomas.
d. Latent myeloma.

Answer 21

c. Senile angiomas.

Rationale: Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear
on the trunk of adults over 30 years old.

Question 22

A 65 year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?

a. Anasarca.
b. Scleroderma.
c. Pedal erythema.
d. Clubbing of the nails.

Answer 22

d. Clubbing of the nails.

Rationale: Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

Question 23

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infants mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:

a. Cafe au lait.
b. Carotenemia.
c. Acrocyanosis.
d. Cutis marmorata.

Answer 23

d. Cutis marmorata.

Rationale: Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those
born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A cafe au lait spot is a large round or oval patch of light-brown pigmentation.
Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

Question 24

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:

a. Keratoses.
b. Xerosis.
c. Chloasma.
d. Acrochordons.

Answer 24

c. Chloasma.

Rationale: In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

Question 25

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer.
During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction?

a. Senile lentigines, which do not become cancerous.
b. Actinic keratoses, which are precursors to basal cell carcinoma.
c. Acrochordons, which are precursors to squamous cell carcinoma.
d. Seborrheic keratoses, which do not become cancerous.

Answer 25

d. Seborrheic keratoses, which do not become cancerous.

Rationale: Seborrheic keratoses appear like dark, greasy, stuck-on lesions that primarily develop on the
trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

Question 26

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, What causes these liver spots? The nurse tells her, They are:

a. Signs of decreased hematocrit related to anemia.
b. Due to the destruction of melanin in your skin from exposure to the sun.
c. Clusters of melanocytes that appear after extensive sun exposure.
d. Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.

Answer 26

c. Clusters of melanocytes that appear after extensive sun exposure.

Rationale: Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

Question 27

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a :

a. Bulla.
b. Wheal.
c. Nodule.
d. Papule.

Answer 27

Papule.

Rationale: A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter,
and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

Question 28

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

a. Lesions that run together.
b. Annular lesions that have grown together.
c. Lesions arranged in a line along a nerve route.
d. Lesions that are grouped or clustered together.

Answer 28

a. Lesions that run together.

Rationale: Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

Question 29

A patient has had a terrible itch for several months that he has been continuously scratching. On examination, the nurse might expect to find:

a. A keloid.
b. A fissure.
c. Keratosis.
d. Lichenification.

Answer 29

d. Lichenification.

Rationale: Lichenification results from prolonged, intense scratching that eventually thickens the skin and
produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

Question 30

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, The physician is referring to the:

a. Blue dilation of blood vessels in a star-shaped linear pattern on the legs.
b. Fiery red, star-shaped marking on the cheek that has a solid circular center.
c. Confluent and extensive patch of petechiae and ecchymoses on the feet.
d. Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color.

Answer 30

c. Confluent and extensive patch of petechiae and ecchymoses on the feet.

Rationale: Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

Question 31

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:

a. Eczema.
b. Impetigo.
c. Herpes zoster.
d. Diaper dermatitis.

Answer 31

Impetigo.

Rationale: Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

Question 32

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?

a. Pink, papular rash on the face and neck.
b. Pruritic vesicles over her trunk and neck.
c. Hyperpigmentation on the chest, abdomen, and back of the arms.
d. Red-purple, maculopapular, blotchy rash behind the ears and on the face.

Answer 32

d. Red-purple, maculopapular, blotchy rash behind the ears and on the face.

Rationale: With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth
day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, redbased spots in the mouth are known as Koplik spots.

Question 33

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patch-like lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:

a. Measles (rubeola).
b. Kaposis sarcoma.
c. Angiomas.
d. Herpes zoster.

Answer 33

b. Kaposis sarcoma.

Rationale: Kaposis sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint
pink lesions over the patients temple and beard areas. Measles is characterized by a red-purple
maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first
observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and
legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that
commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to
1 cm in size that are elevated with a cavity containing clear fluid.

Question 34

A 45 year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:

a. Tinea capitis.
b. Folliculitis.
c. Toxic alopecia.
d. Seborrheic dermatitis.

Answer 34

a. Tinea capitis.

Rationale: Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious.

Question 35

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stub-like hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:

a. Folliculitis that can be treated with an antibiotic.
b. Traumatic alopecia that can be treated with antifungal medications.
c. Tinea capitis that is highly contagious and needs immediate attention.
d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

Answer 35

d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

Rationale: Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped
patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It
occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or
watching television.

Question 36

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

a. Severe obesity.
b. Childhood growth spurts.
c. Severe dehydration.
d. Connective tissue disorders such as scleroderma.

Answer 36

c. Severe dehydration.

Rationale: Decreased skin turgor is associated with severe dehydration or extreme weight loss.

Question 37

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?

a. Heart failure
b. Venous thrombosis
c. Local inflammation
d. Blockage of lymphatic drainage

Answer 37

a. Heart failure

Rationale: NS: A
Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

Question 38

A 40 year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

a. Tell the patient to watch the lesion and report back in 2 months.
b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms.
c. Ask additional questions regarding environmental irritants that may have caused this condition.
d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle.

Answer 38

b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms.

Rationale: The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and
diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

Question 39

The nurse is assessing for clubbing of the fingernails and expects to find:

a. Nail bases that are firm and slightly tender.
b. Curved nails with a convex profile and ridges across the nails.
c. Nail bases that feel spongy with an angle of the nail base of 150 degrees.
d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

Answer 39

d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

Question 40

The nurse is admitting a 75-year-old man with a 50-year history of smoking 1 pack of cigarettes per day. Among the patient’s concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is

a. pitting.
b. thickening and discoloration of the nail bed.
c. clubbing.
d. brittleness and cracking of the nails.

Answer 40

C. Clubbing.

Rationale: Chronic hypoxia decreases oxygenation of the distal extremities. Associated clubbing changes will be evident.

Question 41

All of the following skin lesions may be papular except:

a. warts.
b. acne.
c. nevi.
d. herpes zoster.

Answer 41

D. Herpes zoster.

Rationale: The lesions of herpes zoster are vesicular, warts and nevi or moles are benign papules, and acne lesions include papules as well as pustules.

Question 42

The ABCDEs of melanoma identification do not include:

a. Asymmetry: one half does not match the other half.
b. Birthmark: café au lait spot that does not fade.
c. Color: pigmentation is not uniform; there may be shades of tan, brown, and black as well as red, white, and blue.
d. Diameter: greater than 6 mm.
e. Evolving: any change in size, shape, color, elevation—or any new symptom such as bleeding, itching, or crusting.

Answer 42

B. Birthmark: Café au lait spot that does not fade.

Rationale: The B in ABCDE stands for irregular border of the lesion.

Question 43

A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion?

a. Patch
b. Plaque
c. Papule
d. Macule

Answer 43

A. Patch.

Rationale: Patches are nonpalpable, defined lesions larger than 1.0 cm. Macules have the same characteristics of patches but are less than 1.0 cm. Papules are solid, raised, palpable lesions less than 1.0 cm. Plaques are papules larger than 1.0 cm.

Question 44

When assessing hydration, the nurse will:

a. pinch a fold of skin on the medial aspect of the forearm and observe for recoil to normal.
b. pinch a fold of skin on the abdomen and observe for recoil to normal.
c. pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.
d. pinch a fold of skin on the head and allow for skin to recoil in children.

Answer 44

C. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.

Rationale: To assess turgor in an adult, the most reliable method is to pinch a fold of skin on the anterior chest, release, and observe for the skin to promptly recoil to its original state.

Question 45

A fair-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? (Select all that apply)

a. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer.
b. Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure.
c. Avoid sun exposure between 10 AM and 4 PM to reduce UVA and UVB exposure.
d. A mild sunburn is acceptable in a fair-skinned blonde person.

Answer 45

A. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer; B. Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure; C. Avoid sun exposure between 10 AM and 4 PM to reduce UVA and UVB exposure.

Rationale: Teaching the patient about the harmful effects of UVA and UVB exposure will help her understand the importance of sun protection. Sunscreens or sunblocks applied in time for the skin to fully absorb them afford the best protection. Avoiding the sun during the midday decreases exposure to intense and harmful UVA and UVB rays.

Question 46

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. Which of the following infectious illnesses does the nurse suspect?

a. Varicella
b. Measles
c. Roseola
d. Herpes simplex

Answer 46

A. Varicella.

Rationale: Varicella (chicken pox) is a highly contagious infectious disease. It occurs most frequently in children. It is characterized by single to multiple erythematous vesicles anywhere on the body. As the disease progresses, the vesicles progress into shallow ulcers covered with scabs. Measles is a rash of macules and papules. Herpes simplex is generally localized to one area of the body and consists of grouped vesicles on an erythematous base. Roseola is a macular and papular rash.

Question 47

A 24 year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions?

a. Satellite
b. Discrete
c. Confluent
d. Zosteriform

Answer 47

A. Satellite.

Rationale: Single lesions in close proximity to a larger lesion are termed satellite lesions. Discrete distribution identifies lesions that are totally separate from one another. Confluent lesions are several lesions that have merged together, and zosteriform distribution identifies lesions, which follow a dermatomal pathway.

Question 48

A 22year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion?

a. Crust
b. Lichenification
c. Keloid
d. Scale

Answer 48

C. Keloid.

Rationale: Keloid is an excessive accumulation of fibrin tissue in response to wound healing. Lichenifications are exaggerated skin lines as a result of chronic irritation or scratching. Crust is a dried secretion from a primary lesion, and a scale results from excessive proliferation of the upper epidermal skin layers without normal shedding of dead cells.

Question 49

An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age related variation?

a. Thinning of the skin
b. Increased skin turgor
c. Hypopigmented flat macules and patches over sun-exposed areas
d. Multiple purplish bruises on the arms and legs

Answer 49

A. Thinning of the skin.

Rationale: The skin layers thin with aging, resulting in decreased skin turgor. Thinned skin is subject to increased trauma from shearing or friction, which increases the risk for purpuric lesions. Nevertheless, such lesions are not a normal variant of aging skin. Hyperpigmented macules and papules (commonly seborrheic keratoses) are present on sun-damaged skin.

Question 50

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?

a. Papule
b. Pustule
c. Cyst
d. Vesicle

Answer 50

B. Pustule.

Rationale: Pustules are palpable erythematous lesions containing pus or other infectious material. Papules are solid. Cysts can contain serous as well as infectious substances and extend into the deeper layers of skin. Vesicles are small, thin-roofed lesions containing clear serous fluid.

Question 51

Skin assessment findings reflect overall health, ______, and nutritional status.

Answer 51

Hydration

Question 52

Skin color variations largely result from the amounts and proportions of pheomelanin and eumelanin produced by the ______.

Answer 52

Melanocytes

Question 53

Skin changes owing to cultural variations include Mongolian spots, café au lait markings, ______, melasma, Hori nevus, nevus of Ota, and ashy dermatoses.

Answer 53

Keloids

Question 54

Loss of elastin, collagen, and subcutaneous fat result in decreased resilience, sagging, wrinkling, and increased fragility of the ______ in the older adult.

Answer 54

Skin

Question 55

The ABCDEs of melanoma detection include Asymmetry, Border irregularity, Color, Diameter of more than ______, and Evolution of the lesion over time.

Answer 55

6 mm

Question 56

Skin self-examination helps patients identify problematic ______.

Answer 56

Lesions

Question 57

Common integumentary symptoms include ______, rash, lesions, or wounds.

Answer 57

Pruritus

Question 58

Coining and ______ are self-treatments performed as cultural home remedies.

Answer 58

Cupping

Question 59

______ involves inspection of general color, texture, moisture, turgor, and temperature, and focused inspection and palpation of rashes, lesions, and wounds.

Answer 59

Skin assessment

Question 60

When assessing a lesion, identify configuration, pattern, morphology, ______, distribution, and exact body location.

Answer 60

Size

Question 61

Assess a ______ for location, size, color, texture, drainage, margins, surrounding skin, and healing status.

Answer 61

Wound

Question 62

Depth of a ______ can be superficial, superficial dermal, dermal, or full thickness.

Answer 62

Burn

Question 63

Assessment of the nails and ______ is performed as a part of the skin assessment.

Answer 63

Hair

Question 64

Unexpected skin findings include infection, ______, infestation, growths and tumors, trauma, and ulcers.

Answer 64

Inflammation

Question 65

Common nursing diagnoses related to the ______ system include impaired skin integrity, impaired tissue integrity, pain, and risk for infection.

Answer 65

Integumentary

Question 66

Poor skin turgor may be a reflection of loss of_______ rather than dehydration.

Answer 66

collagen

Question 67

Turgor in the older adult is best evaluated on the inner aspect of the thigh, _______ space, or over the sternum.

Answer 67

subclavicular

Question 68

If a patient has a specific concern about his or her skin, inspect the area or lesion _____ (before/after) asking questions. Often, once you have identified the type of lesion (inflammatory, infectious, tumor, or altered integrity), you can focus questions to address the specific type of lesion. For instance, if a patient is scratching a deep, pink, scaly lesion on his elbow, you may want to inquire about atopic illness or contact irritants instead of melanoma.

Answer 68

before

Question 69

Is the following statement true or false?

An Arabic woman comes to the clinic for the first time. One of the cultural considerations the nurse must take into consideration is that a chaperone must be in the room when this woman is assessed.

Answer 69

True

Rationale: Cultural variations can include a refusal from a patient to remove his or her head covering or a requirement for the patient to have a chaperone present during the examination, particularly if the examiner is not the same sex as the patient.

Question 70

You are caring for an 82-year-old male patient who has been hospitalized after a fall. A family member asks the nurse how often his or her father should bathe. What is the nurse’s best answer?
	A. Twice daily
	B. Daily
	C. Every 2 to 3 days
	D. Weekly

Answer 70

C. Every 2 to 3 days

Rationale: Elderly patients need to bathe less often, usually every 2 to 3 days.