Hesi Integumentary

Question 1

The nurse questions the client about her symptoms. What should the nurse ask about first?

History of skin conditions.

What the client has done to treat the itching.

Severity and location of the itching.

Recent exposure to lice or scabies.

Answer 1

Severity and location of the itching.

Question 2

The nurse questions the client about anaphylaxis. What client cues would indicate the presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be correct.)
Select all that apply

Drooling.

Shortness of breath.

Diaphoresis.

Flushed or pale skin.

Tremors or seizures.

Answer 2

Drooling.

Shortness of breath.

Flushed or pale skin.

Question 3

The nurse prepares to administer diphenhydramine 50 mg orally. The tablet is supplied in a 25 mg dose. How many tablets should the nurse give?

Answer 3

2

Question 4

The nurse teaches the client about diphenhydramine. Which information should the nurse include? (Select all that apply. One, some, or all options may be correct.)
Select all that apply

Diphenhydramine blocks the effect of the histamine response to reduce itching.

Diphenhydramine products contain aspirin, so observe for signs of bleeding.

This medication may cause drowsiness.

Blurred vision or loss of balance are potentially serious side effects of this medication.

This medication may cause an increase in secretions and moisten mucous membranes.

Answer 4

Diphenhydramine blocks the effect of the histamine response to reduce itching.

This medication may cause drowsiness.

Blurred vision or loss of balance are potentially serious side effects of this medication.

Question 5

The nurse begins her assessment of the integumentary system. Select the techniques the nurse should perform.
Select all that apply

Percussion.

Palpation.

Inspection.

Auscultation.

Answer 5

Palpation.

Inspection.

Question 6

The nurse observes that the client’s skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess?

Earlobes.

Hair follicles.

Cheeks and chin.

Conjunctivae

Answer 6

Conjunctivae

Question 7

What action should the nurse perform if rapid facial flushing is observed?

Observe the color of the sclerae.

Measure the oxygen saturation.

Check for loss of skin integrity.

Ask about any feelings of anxiety.

Answer 7

Ask about any feelings of anxiety.

Question 8

The nurse observes that there are numerous blackheads around client’s chin and nose. What action should the nurse take in response to this finding?

Note any pustules or nodules.

Ask about a history of eczema.

Measure for pitting edema.

Palpate the areas for tenderness.

Answer 8

Note any pustules or nodules.

Question 9

What health promotion question is most important for the nurse to ask the client?

“Do you tend to bite or chew your nails?”

“What do you use to cleanse your skin?”

“How often do you use a tanning booth?”

“Do you use a hair coloring product?”

Answer 9

“How often do you use a tanning booth?”

Question 10

What cues support the nurse’s assessment regarding the client’s fluid status?

Areas of skin bruising.

Rapid facial flushing.

Dry mucus membranes.

Shiny appearance of the forehead.

Answer 10

Dry mucus membranes.

Question 11

The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask? (Select all that apply. One, some, or all options may be correct.)
Select all that apply

“Have you experienced nausea or vomiting recently?”

“How much water are you drinking per day?”

“Have you experienced diarrhea recently?”

“Are you feeling dizzy?”

“Is your mouth dry?”

Answer 11

“Have you experienced nausea or vomiting recently?”

“How much water are you drinking per day?”

“Have you experienced diarrhea recently?”

Question 12

The nurse observes multiple moles on the client’s skin. What question is most important to ask the client?

“When did you first notice the presence of the moles?”

“Do the moles on your arms make you feel self-conscious?”

“Where are all your moles located?”

“Have any of your moles changed in size or appearance?”

Answer 12

“Have any of your moles changed in size or appearance?”

Question 13

What additional observation is important in assessing the mole?

The border of the mole is smooth.

The mole is surrounded by freckles.

There is no inflammation around the mole.

The mole does not blanche when compressed.

Answer 13

The border of the mole is smooth.

Question 14

The client points out a small (1 mm), smooth, slightly raised bright red dot located on the abdomen. The client asks the nurse to examine that spot as well. How should the nurse proceed?

Apply pressure over the lesion and observe for blanching.

Advise the client to be examined by a healthcare provider.

Offer assurance that this lesion is not an abnormal finding.

Determine if the client experienced any trauma at the site.

Answer 14

Offer assurance that this lesion is not an abnormal finding.

Question 15

The nurse observes that the nail surface is slightly curved and the angle of the nail base is 160 degrees. What action should the nurse take in response to this finding?

Ask the client about any current or past use of cigarettes.

Continue the assessment, noting the color of the nail surface.

Use a pulse oximeter to measure the oxygen saturation.

Assess for the presence of Beau’s lines.

Answer 15

Continue the assessment, noting the color of the nail surface.

Question 16

While assessing the client’s nails, it is most important for the nurse to follow up on which assessment finding?

Brittle nail surface.

Ragged cuticles.

Firm nail base.

Traumatized nail folds.

Answer 16

Brittle nail surface.

Question 17

Which assessment is most important for the nurse to complete?

Assess the color distribution of the hair dye.

Check the client’s hair for split ends.

Observe the texture and distribution of hair growth on the scalp.

Note the pattern of hair growth around the client’s forehead

Answer 17

Observe the texture and distribution of hair growth on the scalp.

Question 18

The client states, “My scalp itches sometimes.” What action should the nurse take first?

Instruct the client about dandruff treatments.

Observe the client’s hair shafts and scalp.

Remind the client not to share hairbrushes.

Question the client regarding frequency of shampooing hair

Answer 18

Observe the client’s hair shafts and scalp.

Question 19

The nurse observes the overall hair distribution on the client’s face and body. There is visible hair growth on the forearms but no visible hair on the lower extremities. The client has thin eyelashes and eyebrows and fine, downy facial hair. What action should the nurse take in response to these observations?

Ask the client if the excessive hair growth on the arms is concerning.

Note the absence of normal hair growth patterns on the client’s face.

Document the areas of alopecia as an indication of the client’s poor nutrition.

Move on to the next area of assessment since the findings are within normal limits.

Answer 19

Move on to the next area of assessment since the findings are within normal limits.

Question 20

The nurse observes several bruises of various colors across the client’s lower abdomen. How should the nurse interpret this assessment finding?

Repeated injury over a period of time.

Recent injury with different sized objects.

Skin exposure to hot and cold objects.

The client is the victim of abuse.

Answer 20

Repeated injury over a period of time.

Question 21

The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?

Ask the client how these burns occurred.

Palpate the areas for warmth and swelling.

Immediately measure and record the vital signs.

Document the location of the bruises and petechiae.

Answer 21

Document the location of the bruises and petechiae.

Question 22

The nurse expresses concern regarding the client’s bruise. What action should the nurse take to initiate the abuse assessment?

Determine if the client is sexually active.

Ask the client if someone else caused the injuries.

Encourage the client to describe the family structure.

Advise the client of the right to legal counsel during the interview.

Answer 22

Ask the client if someone else caused the injuries.

Question 23

To gather data related to the pattern of abuse, what action should the nurse take first?

Instruct the client that there is no point in denying the pattern of abuse because of the varying colors of the bruises.

Determine if the client’s partner threatened to hurt the client when trying to break up with the partner.

Ask the client about the client’s use of any illegal drugs or frequency of alcohol abuse since they have been dating.

Provide a calendar for the client to mark the dates when any violent and abusive behavior by the client’s partner occurred.

Answer 23

Provide a calendar for the client to mark the dates when any violent and abusive behavior by the client’s partner occurred.

Question 24

What finding should the nurse expect in response to the client’s itching?

Purpura.

Hirsutism.

Urticaria.

Pustules.

Answer 24

Urticaria.

Question 25

The nurse observes raised, pink wheals on the client’s neck. How should the nurse respond to this observation?

Ask if the client has been stung by an insect recently.

Explain that antibiotics will need to be prescribed.

Apply a warm compress directly over the wheals.

Offer assurance that this is a temporary response.

Answer 25

Offer assurance that this is a temporary response.

Question 26

How should the nurse document the information obtained when charting the client’s abuse assessment?

Clarify that the information was obtained after the client took diphenhydramine.

Quote the client’s responses to the questions as verbatim as possible.

Summarize the abusive events without directly quoting the client.

Refrain from including information that might identify the alleged abuser.

Answer 26

Quote the client’s responses to the questions as verbatim as possible.