Tissue Integrity Flashcards
An older patient has developed age spots and is concerned about skin cancer. How would the
nurse instruct the patient to perform skin checks to assess for signs of skin cancer?
“Monitor spots for color change.”
The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist
A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?
Protection from excessive ultraviolet (UV) exposure
Protection from excessive UV exposure is important to prevent tissue damage
A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching?
“I don’t bother with sunscreen on overcast days.”
The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other
options will all prevent skin cancer
The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient.
Which action indicates the nursing assistant has understood the nurse’s teaching?
Turning the patient at least every 2 hours
The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the
patient must be turned more frequently.
A patient was given a patch test to determine what allergen was responsible for their atopic
dermatitis. The provider prescribes a steroid cream. What important instructions should the
nurse give to the patient?
Apply a thin coat to affected areas; avoid the face and groin.
The patient should avoid the face and groin area as these areas are sensitive and may become
irritated or excoriated
A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions
will the plan of care focus primarily on?
Decreasing pruritus
Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity
To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the
nurse would advise the patient to do which of the following?
Apply sunscreen 30 minutes prior to exposure
Wearing sunglasses and sunscreen are recommended by the National Cancer Institute
A nurse is conducting community education classes on skin cancer. One participant says to
the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women. Is
this true?” The nurse’s most helpful response would be which of the following?
“That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.”
