Exam 2 - Skin

Question 1

A teacher notifies the school nurse that many of the students in her third-grade class have been scratching their heads and complaining of intense itching of the scalp. The nurse notices tiny white material at the base of a student’s hair shaft. What condition does this assessment reflect?

1. Tinea capitis
2. Pediculosis capitis
3. Dandruff
4. Scabies

Answer 1

2
Pediculosis capitis (head lice) is characterized by tine white nits (eggs) that attach to the base of the hair shaft and are highly contagious. Tinea capitis is characterized by a red, scaly, rash with central clearing in the well-defined margins. Dandruff is oten mistaken for head lice, but dandruff can be easily removed from the hair shaft. Nits adhere to the hair shaft and are not easy to remove. Scabies forms burrow under the skin and cause intense nighttime itching.

(Illustrated, p 235)

Question 2

What is the type of skin cancer that is most difficult to treat?

1. Dysplastic nevi
2. Malignant melanoma
3. Basal cell epithelioma
4. Squamous cell epithelioma

Answer 2

2
Malignant melanoma is the most difficult to treat; it involves extensive full-thickness skin resections and has the poorest prognosis. Dysplastic nevi are thought to be a precursor of malignant melanoma, although they are not considered malignant in the initial stage. Basal cell epithelioma and squamous cell epithelioma are easier to treat and do not metastasize as does melanoma.

(Illustrated, p 235)

Question 3

An older adult client has an open wound over the coccyx that extends through the dermis and subcutaneous tissue, exposing the deep fascia. The wound edges are distinct, and the wound bed is a pink-red color. There is no bruising or sloughing. The nurse would correctly document this ulcer as what stage?

1. Stage I
2. Stage II
3. Stage III
4. Stage IV

Answer 3

3
This is classified as a stage III pressure ulcer because of full-thickness tissue loss extending to the deep fascia. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. A stage I pressure ulcer is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. A stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough, which may also present as an intact or open/ruptured serum-filled blister. A stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining or tunneling.

(Illustrated, p 235)

Question 4

The nurse understands what scaling around the toes, blistering and pruritus is characteristic of what condition?

1. Eczema
2. Psioriasis
3. Tinea pedis
4. Pediculosis corporis

Answer 4

3
Scaling, itching, and redness are common signs of tinea pedis or athlete’s foot. Eczema or atopic dermatitis in adults is characterized by reddened lesions in antecubital and popliteal space with pruritis or in children on cheeks, arms, and legs. Psoriasis is a benign condition of the skin where there are silvery scaling plaques on the skin, commonly the elbows, knees, palms, and soles of the feet. Pediculosis corporis is body lice and is a parasitic infection.

(Illustrated, p 235)

Question 5

What physical characteristics of a client would place them at highest risk for development of malignant melanoma?

1. Light to pale skin, blond hair, blue eyes
2. Olive complexion, oily skin, dark eyes
3. Dark skin with freckles, dry flaky skin, hazel eyes
4. Coarse skin, ruddy complexion, brown eyes

Answer 5

1
People with light to pale skin and who are excessively exposed to sunlight are most at risk for development of malignant melanoma. Dark-skinned and olive-skinned individuals have more melanin in their skin, which provides a measure of protection from UV exposure. Although those with a ruddy complexion are more prone to the development of skin cancers, the coarseness of the skin does provide some protection from the sun’s harmful rays.

(Illustrated, p 235)

Question 6

Herpes zoster has been diagnosed in an older adult client. What will the nursing management include?

1. Apply antifungal cream to the areas daily.
2. Maintain client on contact precautions.
3. Instruct on the need for sexual abstinence.
4. Closely inspect the perineal area for lesions.

Answer 6

2
Herpes zoster is considered infectious and contact precautions should be used with an older adult client. Antiviral medications would be given instead of antifungal agents. Lesions are usually not along the sensory dermatomes (waist, neck, face) and not in the perineal area, which is HSV-2. There is no need for sexual abstinence, although a condom should be worn if contact may occur with the lesions.

(Illustrated, p 235)

Question 7

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Select all that apply:
_____ 1. Position the client directly on the trochanter when side-lying.
_____ 2. Avoid the use of donut-type devices.
_____ 3. Massage bony prominences.
_____ 4. Elevate the head of the bed no more than 30 degrees when possible.
_____ 5. When the client is side-lying, use the 30-degree lateral inclined position.
_____ 6. Avoid uninterrupted sitting in any chair or wheelchair.

Answer 7

2, 4, 5, 6
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. When placing the client in a side-lying position, use the 30 degree lateral inclined position. Do not place the client directly on the trochanter, which can create pressure over the bony prominence. Avoid the use of donut-shaped cushions because they reduce blood supply to the area, which can lead to extension of the area of ischemia. Bony prominences should not be massaged, because this increases the risk for capillary breakage and injury to underlying tissue leading to pressure ulcer formation.

(Illustrated, p 235)

Question 8

The nurse is teaching self-care to an older adult client. What would the nurse encourage the client do for his dry, itchy skin?

1. Apply a moisturizer on all dry areas daily.
2. Shower twice a day with a mild soap.
3. Use a pumice stone and exfoliating sponge on areas to remove dry scaly patches.
4. Wear protective pads on areas that show the most dryness.

Answer 8

1
Dry skin should be moisturized daily and as needed, especially after the client takes a bath. The number of baths and showers should be limited. Exfoliation will remove the dry epidermal layer, but underlying areas also need moisturizing. Protective pads do nothing to provide moisture to dry areas.

(Illustrated, p 235)

Question 9

What is the priority assessment for a client who has sustained burns on the face and neck?

1. Spreading, large, clear vesicles
2. Increased hoarseness
3. Difficulty with vision
4. Increased thirst

Answer 9

2
When there is evidence of burns around the face, the airway should be carefully assessed. Increased respiratory rate and hoarseness may be the first sign of respiratory complications. Large, clear vesicles are expected on burns of second degree or worse and are not a sign of complication. Difficulty with vision may be of concern, but it is not life threatening like respiratory distress. Increased thirst is common in the first few hours following a burn because of fluid shift into the extravascular space.

(Illustrated, p 235)

Question 10

A client has sustained a third-degree burn. What would the nurse expect to find during assessment of the burn?

1. Area reddened, blanches with pressure, no edema
2. Blackened skin and underlying structures
3. Thick, clear blisters, underlying skin edematous and erythematous
4. Dry white, charred appearance, damage to subcutaneous tissues

Answer 10

4
All of the skin is destroyed in a full-thickness or third-degree burn. Often, it has a dry appearance and may be white or charred and usually requires skin grafting to repair. An area reddened that blanches with pressure is indicative of a superficial first-degree burn (partial-thickness). Characteristics of a full-thickness fourth-degree burn include blackened skin and into underlying muscle and bone structures. Thick, clear blisters, underlying skin edematous and erythematous are characteristics of a deep second-degree burn (partial-thickness).

(Illustrated, p 235)

Question 11

Macule

Answer 11

A flat, circumcised discolored lesion

E.g. Hyperpigmentation, erythema, telangiectasias, purpura

Question 12

Papule

Answer 12

Lesions 1 cm or less in diameter because of infiltration or hyperplasia of dermis

E.g. Verruca (warts), lichen planus, nevus

Question 13

Patch

Answer 13

Flat, irregular lesion larger than a macula

E.g. Vitiligo

Question 14

Plaque

Answer 14

Lesions with a large surface area, larger laterally than in height

E.g. Psoriasis, eczema

Question 15

Wheal

Answer 15

Transient lesion with well-defined and often changing borders caused by edema of the dermis

E.g. Hives, angioedema

Question 16

Nodule

Answer 16

Palpable circumcised lesion 1 to 2 cm in diameter located in the epidermis, dermis, or hypodermis; smooth to ulcerated

E.g. Benign or malignant tumors, foreign body inflammation, calcium deposits

Question 17

Tumor

Answer 17

A well-demarcated solid lesion greater than 2 cm in diameter

E.g. Fibroma, lipoma, melanoma, hemangioma

Question 18

Vesicle and bulla

Answer 18

A fluid-filled, thin-walled lesion; a bulla is a vesicle greater than 0.5 cm in diameter

E.g. Herpes zoster, impetigo, pemiphigus, second-degree burns

Question 19

Pustule

Answer 19

Lesion containing an exudate of white blood cells

E.g. Acne, pustular psoriasis

Question 20

Cyst

Answer 20

An encapsulated mass of dermis or subcutaneous layers, solid or fluid filled

E.g. Sebaceous cyst

Question 21

Comedone

Answer 21

Plugged hair follicle

E.g. Blackhead, whitehead

Question 22

Telangiectasia

Answer 22

Dilated, superficial blood vessels

E.g. Rheumatoid arthritis, hepatitis

Question 23

Scale

Answer 23

Accumulation of loose stratum corneum from cellular retention or cellular overproduction

E.g. Psoriasis

Question 24

Lichenification

Answer 24

Thickening, toughening of the skin with accentuation of skin lines caused by scratching

E.g. Chronic dermatitis

Question 25

Keloids

Answer 25

Elevated, irregular, progressively grows beyond the boundaries of wound; excessive collagen formation during healing

E.g. Burns, autosomal patterns dominate in dark-pigmented skin

Question 26

Scar

Answer 26

Thin or thick fibrous tissue

E.g. Healed laceration, burn, surgical incision

Question 27

Excoriation

Answer 27

Loss of epidermis with exposed dermis

E.g. Scratches

Question 28

Fissure

Answer 28

Linear crack or break exposing dermis

E.g. Athlete’s foot, cheilosis

Question 29

Erosion

Answer 29

Moist, red break in epidermis, follows rupture of vesicle or bulla, larger than fissure

E.g. Chickenpox, diaper dermatitis

Question 30

Ulcer

Answer 30

Loss of epidermis and dermis

E.g. Pressure sores, basal cell carcinoma

Question 31

Atrophy

Answer 31

Thinning of the epidermis or dermis caused by decreased connective tissue

E.g. Thin facial skin in elderly, striae of pregnancy

Question 32

Petechiae

Answer 32

A circumcised area of blood less than 0.5 cm in diameter

E.g. Thrombocytopenia

Question 33

Purpura

Answer 33

A circumcised area of blood greater than 5 cm in diameter

E.g. Bruises

Question 34

Burrow

Answer 34

A narrow, raised irregular channel

E.g. Parasitic burrowing

Question 35

The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder?

1. Clear, thin nail beds
2. Red-purplish scaly lesions
3. Oily skin and no episodes of pruritis
4. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions

Answer 35

4
Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Thickening, pitting, and discoloration of the nails occur. Pruritus may occur. The lesions in psoriasis are not red-purplish scaly lesions.

(Yellow book, p 585)

Question 36

The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test?

1. Patch test
2. Skin biopsy
3. Culture of the lesion
4. Wood’s light examination

Answer 36

3
With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

(Yellow book, p 585)

Question 37

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion?

1. Metastasis is rare.
2. Melanoma is encapsulated.
3. Melanoma is highly metastatic.
4. Melanoma is characterized by local invasion.

Answer 37

3
Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person’s survival depends on early diagnosis and treatment.

(Yellow book, p 585)

Question 38

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?

1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border

Answer 38

1
A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a form, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

(Yellow book, p 585)

Question 39

The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?

1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis

Answer 39

4
In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open, or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

(Yellow book, p 585)

Question 40

The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply.

1. The nurse who never had roseola
2. The nurse who never had mumps
3. The nurse who never had chickenpox
4. The nurse who never had German measles
5. The nurse who never received the varicella-zoster vaccine

Answer 40

1, 2, 4
Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

(Yellow book, p 586)

Question 41

Cancerous changes in a nevus (mole) - How would you recognize them? (e.g., size, pigment, growth)

Answer 41

A – asymmetry
B – border (borders are notched, uneven, or blurred)
C – color (color is uneven)
D – diameter (dysplastic > 5 mm in diameter)
E – evolution (any mole that undergoes change = immediate medical attention)

Question 42

Pressure ulcers - be able to recognize the stage by its description.

Answer 42

Stage I
- Defined area of persistent redness in a lightly pigmented skin or an area of persistent redness with blue or purple hues in darker skin
Stage II
- Partial-thickness loss of skin involving the epidermis or dermis, or both.
- Ulcer is superficial and presents clinically as an abrasion, a blister, or a shallow crater
Stage III
- Full-thickness loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.
- Ulcer manifests as deep crater with or without undermining adjacent tissue
Stage IV
- Full-thickness skin loss and necrosis with extensive destruction or damage to the underlying subcutaneous tissues that may extend to involve muscle, bone, and supporting structures (e.g. tendon or joint capsule)

Question 43

Clinical manifestations of herpes simplex

Answer 43

HSV-1 associated with oropharynx infections (labial herpes), and spread by respiratory droplets or by direct contact with infected saliva (also occupational hazards)
Primary HSV-1 symptoms:
- “Cold sore” or “fever blister” most common manifestation
- Fever
- Sore throat
- Ulcers of the lips, tongue, palate, and buccal mucosa
Symptoms most often occur in young children
HSV-2 causes genital herpes

Question 44

Clinical manifestations of herpes zoster

Answer 44

Caused by reactivation of varicella-zoster virus; can occur during any immunocompromised state in a client with a history of chickenpox
- Contagious to individuals who have never had chickenpox and who have not been vaccinated against the disease
Symptoms:
- Lesions preceded by prodrome consisting of burning pain, tingling sensation, extreme sensitivity of the skin to touch, and pruritus along the affected dermatome (1-3 days)
- Unilaterally clustered skin vesicles along peripheral sensory nerves on trunk, thorax, or face
- Fever, malaise
- Burning and pain
- Pruritus
- Paresthesia

Question 45

Clinical manifestations of Onchomycosis (tinea unguium)

Answer 45

• Tinea of the nails (finger or toe)
• Nails turn yellow or brown
• Happens with people with artificial nails

Question 46

Clinical manifestations of Paronchia

Answer 46

• Acute or chronic infection of the cuticle – inflammation of cuticle

Question 47

Clinical manifestations of Psoriasis

Answer 47

Chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches; however break in skin integrity can lead to an infection in the affected area
Symptoms:
- Pruritus
- Shedding: silvery, white scales on a raised, reddened round plaque that usually affects the scalp, knees, elbows, extensor surfaces of arms and legs, and sacral regions

Question 48

Clinical manifestations of Tinea capitus

Answer 48

• Scalp, “ringworm”
• Most common type of fungal infection in children
• Rapid onset, inflamed lesions localized to one area of the head
• Initial lesion – pustular, scaly, round patch with broken hairs

Question 49

Clinical manifestations of Tinea corporis

Answer 49

• Ringworm of the body
• Most commonly lesions are oval or circular patches on exposed skin surfaces and the trunk, back, or buttocks
• Less common are foot and groin infections
• Lesion begins as red papule and enlarges, often with central clearing
• Patches have raised red borders consisting of vesicles, papules, or pustules
• Borders are sharply defined, but lesions may coalesce
• Pruritus, erythema

Question 50

Clinical manifestations of Tinea pedis

Answer 50

• “Athlete’s foot”
• Most common fungal dermatosis, primarily affecting spaces between toes, soles, or sides of feet
• Lesions vary from mildly scaling lesion to painful, exudative, erosive, inflamed lesion with fissuring
• Accompanied by pruritus, pain, and foul odor

Question 51

Clinical manifestations of Rosacea

Answer 51

• Chronic skin disorder of middle-aged and older persons; more common in women
• Symptoms:
  o Blushing
  o Presence of telangiectatic vessels
  o Eruption of inflammatory papules and pustules
• Progression:
  o Repeated episodes of blushing
  o Blush becomes permanent dark red erythema on the nose and cheeks that sometimes extends to forehead and chin
  o This stage often occurs before 20 years of age
• Ocular problems occur in at least 50% of persons with rosacea
  o Eyes that are itchy, burning, or dry
  o A gritty or foreign body sensation
  o Erythema and swelling of the eyelid

Question 52

Clinical manifestations of HPV

Answer 52

• Genital warts
• Highly contagious
• Sexually transmitted
• Cauliflower-like lesions

Question 53

Hirsutism in Women – Common causes

Answer 53

• Ethnic or family trait

- Excessive androgens (especially testosterone)