UNIT 5: Assessment of Integumentary Function

Question 1

1. A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply.
   A. Producing antibodies
   B. Absorbing electrolytes
   C. Maintaining acid–base balance
   D. Physically repelling pathogens
   E. Preventing fluid loss

Answer 1

ANS: D, E
Rationale: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acid–base balance, or electrolyte levels.

Question 2

2. When planning the skin care of a client with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
   A. The scalp
   B. The elbows
   C. The palms of the hands
   D. The knees

Answer 2

ANS: C
Rationale: The epidermis is the thickest over the palms of the hands and the soles of the feet

Question 3

3. A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
   A. Telangiectasias
   B. Ecchymoses
   C. Purpura
   D. Urticaria

Answer 3

ANS: B
Rationale: Telangiectasias consist of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticaria is wheals or hives

Question 4

4. The nurse in an ambulatory care center is admitting an older adult client who has bright red moles on the skin. What benign changes in the skin of an older adult appear as bright red moles?
   A. Cherry angiomas
   B. Solar lentigines
   C. Seborrheic keratoses
   D. Xanthelasmas

Answer 4

ANS: A
Rationale: Cherry angiomas appear as bright red “moles,” while solar lentigines are commonly called “liver spots.” Seborrheic keratoses are described as crusty brown “stuck on” patches, while xanthelasmas appear as yellowish, waxy deposits on the upper eyelids.

Question 5

5. While assessing a dark-skinned client at the clinic, the nurse notes the presence of patchy, milky-white spots. The nurse knows that this finding is characteristic of what diagnosis?
   A. Cyanosis
   B. Addison disease
   C. Polycythemia
   D. Vitiligo

Answer 5

ANS: D
Rationale: With cyanosis, nail beds are dusky. With polycythemia, the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or “external tan,” is associated with Addison disease. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky-white spots, often symmetric bilaterally.

Question 6

6. While waiting to see the health care provider, a client shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the client is demonstrating:
   A. macules.
   B. papules.
   C. vesicles.
   D. pustules

Answer 6

ANS: A

Rationale: A macule is a flat, nonpalpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.

Question 7

7. A dark-skinned client is admitted to the medical unit with liver disease. To correctly assess this client for jaundice, on what body area should the nurse look for yellow discoloration?
   A. Elbows
   B. Lips
   C. Nail beds
   D. Sclerae

Answer 7

ANS: D

Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.

Question 8

8. A nurse is doing a shift assessment on a group of clients after first taking report. An older adult client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client’s chest. The nurse should ask what priority question regarding the presence of a reddened rash?
   A. “Is the rash worse at a particular time or season?”
   B. “Are you allergic to any foods or medication?”
   C. “Are you having any loss of sensation in that area?”
   D. “Is your rash painful?”

Answer 8

ANS: B
Rationale: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the client’s immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

Question 9

9. A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
   A. By avoiding the use of moisturizing lotions on older adults’ skin
   B. By protecting older adults against shearing injuries
   C. By avoiding the use of ice packs to treat muscle pain
   D. By protecting older adults against excessive sweat accumulation

Answer 9

ANS: B
Rationale: Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults’ skin. Ice packs can be used, provided skin is assessed regularly and the client possesses normal sensation.
Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

Question 10

10. A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative allergen?
    A. Skin scrapings
    B. Skin biopsy
    C. Patch testing
    D. Tzanck smear

Answer 10

ANS: C
Rationale: Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.

Question 11

11. A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?
    A. Tzanck smear
    B. Skin biopsy
    C. Patch testing
    D. Skin scrapings

Answer 11

ANS: B
Rationale: A skin biopsy is done to rule out malignancies of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster. Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal infections.

Question 12

12. A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?
    A. E
    B. D
    C. A
    D. C

Answer 12

ANS: B
Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus

Question 13

13. A nurse is working with a client who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation?
    A. Alopecia
    B. Yellowish skin tone
    C. Patchy, bronze pigmentation
    D. Hirsutism

Answer 13

ANS: D
Rationale: Cushing syndrome causes excessive hair growth, especially in women. Alopecia is hair loss from the scalp and other parts of the body. Jaundice causes a yellow discoloration in light-skinned clients, but this does not accompany Cushing syndrome. Clients that have Addison disease exhibit a bronze discoloration to their skin due to increased melanin production

Question 14

14. The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?
    A. An insect bite
    B. Dehydration
    C. Sunburn
    D. Excessive perspiration

Answer 14

ANS: A
Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

Question 15

15. A nurse in a dermatology clinic is reading the electronic health record of a new client. The nurse notes that the client has a history of a primary skin lesion. What skin lesion may this client have?
    A. Crust
    B. Keloid
    C. Pustule
    D. Ulcer

Answer 15

ANS: C

Rationale: A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

Question 16

16. An unresponsive client with a light complexion has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client’s face is a cherry-red color. What should the nurse suspect?
    A. Carbon monoxide poisoning
    B. Anemia
    C. Jaundice
    D. Uremia

Answer 16

ANS: A
Rationale: Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry-red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark-skinned persons manifests as a
yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin.

Question 17

17. A nurse is providing an educational presentation addressing the topic of “Protecting Your Skin.” When discussing the anatomy of the skin, the nurse should state that what cells are responsible for producing the pigmentation of the skin?
    A. Islets of Langerhans
    B. Squamous cells
    C. T cells
    D. Melanocytes

Answer 17

ANS: D

Rationale: Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin. Islets of Langerhans are clusters of cells in the pancreas. Squamous cells are flat, scaly epithelial cells. T cells function in the immune response.

Question 18

18. A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?
    A. Dermis
    B. Subcutaneous tissue
    C. Epidermis
    D. Stratum corneum

Answer 18

ANS: B
Rationale: The subcutaneous tissue, or hypodermis, is the innermost layer of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones. The dermis is the largest portion of the skin, providing strength and structure. The epidermis is the outermost layer of stratified epithelial cells and composed of keratinocytes. The stratum corneum is the outermost layer of the epidermis, which provides a barrier to prevent epidermal water loss.

Question 19

19. While assessing a 25-year-old female, the nurse notes that the client has hair on her lower abdomen. Earlier in the health interview, the client stated that her menses are irregular. The nurse should suspect what type of health problem?
    A. A metabolic disorder
    B. A malignancy
    C. A hormonal imbalance
    D. An infectious process

Answer 19

ANS: C
Rationale: Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen. This is often a normal genetic variation, but if it appears along with irregular menses and weight changes, it may indicate a hormonal imbalance. This combination of irregular menses and hair distribution is inconsistent with metabolic disorders, malignancy, or infection.

Question 20

20. An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client’s course of treatment?
    A. Increased thickness of the subcutaneous skin layer
    B. Increased vascular supply to superficial skin layers
    C. Changes in the character and quantity of bacterial skin flora
    D. Increased time required for wound healing

Answer 20

ANS: D
Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

Question 21

21. A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? Select all that apply.
    A. Palpation of the nailbeds
    B. Palpation of the client’s upper extremities
    C. Palpation of a rash on the client’s trunk
    D. Palpation of a lesion on the client’s upper back
    E. Palpation of the client’s finger joints

Answer 21

ANS: C, D

Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a client’s extremities or fingers unless contact with body fluids is reasonably foreseeable.

Question 22

22. A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client’s susceptibility to heat loss is related to atrophy of what skin component?
    A. Epidermis
    B. Merkel cells
    C. Dermis
    D. Subcutaneous tissue

Answer 22

ANS: D
Rationale: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

Question 23

23. A nurse is reviewing gerontologic considerations relating to the care of clients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
    A. Decreased resistance to ultraviolet radiation
    B. Increased vulnerability to infection
    C. Diminished protection of tissues and organs
    D. Increased risk of skin malignancies

Answer 23

ANS: C
Rationale: Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

Question 24

24. An 80-year-old client is brought to the clinic by one of the client’s children. The client asks the nurse why the client has gotten so many “spots” on the skin. What would be an appropriate response by the nurse?
    A. “As people age, they normally develop uneven pigmentation in their skin.”
    B. “These ‘spots’ are called ‘liver spots’ or ‘age spots.’”
    C. “Older skin is more apt to break down and tear, causing sores.”
    D. “These are usually the result of nutritional deficits earlier in life.”

Answer 24

ANS: A
Rationale: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults’ vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalances.

Question 25

25. A client with vitamin D deficiency is receiving education from the nurse. What would be an appropriate recommendation by the nurse?
    A. Spend time outdoors at least twice per week.
    B. Increase intake of leafy green vegetables.
    C. Promote intake of clear fluids.
    D. Eat red meat at least once per week.

Answer 25

ANS: A

Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). It is estimated that most people need 5 to 30 minutes of sun exposure twice a week in order for this synthesis to occur. Increasing intake of water is not related to resolving vitamin D deficiency. Vitamin D is unrelated to meat and vegetable intake.

Question 26

26. The nurse is performing an initial assessment of a client who has a raised, pruritic rash. The client denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this client at this time?
    A. “Is anyone in your family allergic to anything?”
    B. “How long have you had this abrasion?”
    C. “Do you take any over-the-counter (OTC) drugs or herbal preparations?”
    D. “What do you do for a living?”

Answer 26

ANS: C
Rationale: If suspicious areas are noted, the client is questioned about nonprescription or herbal preparations that might be in use. Ascertaining a family history of allergies would not give helpful information at this time. The client’s lesion is not described as an abrasion. The client’s occupation may or may not be relevant; it is more important to assess for herb or drug reactions.

Question 27

27. A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
    A. “Does anyone in your family have eczema or psoriasis?”
    B. “Have any of your family members been diagnosed with malignant melanoma?”
    C. “Do you have a family history of vitiligo or port-wine stains?”
    D. “Does any member of your family have a history of keloid scarring?”

Answer 27

ANS: A
Rationale: Eczema and psoriasis are known to have a genetic component. This is not true of any of the other listed integumentary disorders.

Question 28

28. A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by the parents for an outbreak of urticaria. What would be the most appropriate question to ask this client’s parents?
    A. “Has your child eaten any new foods today?”
    B: Has your child bathed in the past 24 hours?”
    C. “Did your child go to a friend’s house today?”
    D. “Was your child digging in the dirt today?”

Answer 28

ANS: A
Rationale: Foods can cause skin reactions, especially in children. In most cases, this is a more plausible cause of urticaria than bathing, contact with other children, or soil-borne pathogens.

Question 29

29. A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next?
    A. Obtain a swab for culture.
    B. Assess the characteristics of the lesion.
    C. Obtain a swab for pH testing.
    D. Apply a test dose of broad-spectrum topical antibiotic.

Answer 29

ANS: B

Rationale: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empirical basis.

Question 30

30. The nurse is performing a comprehensive assessment of a client’s skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
    A. By examining the client under a Wood light
    B. By inspecting the client’s skin in direct sunlight
    C. By palpating the client’s skin
    D. By performing percussion of major skin surfaces

Answer 30

ANS: C

Rationale: Inspection and palpation are techniques commonly used in examining the skin. A client would only be examined under a Wood light if there were indications it could be diagnostic. The client is examined in a well-lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin

Question 31

31. A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client’s health history, the nurse should identify what comorbidity as increasing the client’s vulnerability to skin infections?
    A. Chronic obstructive pulmonary disease
    B. Rheumatoid arthritis
    C. Gout
    D. Diabetes

Answer 31

ANS: D

Rationale: Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

Question 32

32. A client with human immune deficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what situation?
    A. A reduction in the client’s CD4 count
    B. A reduction in the client’s viral load
    C. An adverse effect of antiretroviral therapy
    D. Virus-induced changes in allergy status

Answer 32

ANS: A
Rationale: Cutaneous signs may be the first manifestation of human immune deficiency virus (HIV), appearing in more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with low CD4 counts and may become very atypical in immunocompromised people. Viral load increases, not decreases, as the disease progresses. Antiretrovirals are not noted to cause cutaneous changes, and viruses do not change an individual’s allergy status

Question 33

33. Assessment of a client’s leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
    A. Keloid
    B. Ulcer
    C. Fissure
    D. Erosion

Answer 33

ANS: B
Rationale: A pressure ulcer that is stage 2 or greater is one that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

Question 34

34. A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client’s fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?
    A. Eczema
    B. Systemic lupus erythematosus (SLE)
    C. Psoriasis
    D. Chronic obstructive pulmonary disease (COPD)

Answer 34

ANS: C

Rationale: Pitted surface of the nails is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD.

Question 35

35. A client’s health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?
    A. Chronic pain
    B. Impaired skin integrity
    C. Impaired tissue integrity
    D. Disturbed body image

Answer 35

ANS: D
Rationale: Alopecia areata causes hair loss in smaller defined areas. As such, it is common for the client to experience a disturbed body image. Hair loss does not cause pain and does not affect skin or tissue integrity

Question 36

36. A client is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the client develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?
    A. Weak positive
    B. Moderately positive
    C. Strong positive
    D. Severely positive

Answer 36

ANS: B
Rationale: The development of redness, fine elevations, or itching is considered a weak
positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction.

Question 37

37. A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?
    A. Skin biopsy
    B. Patch test
    C. Tzanck smear
    D. Examination with a Wood light

Answer 37

ANS: C
Rationale: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. This is not accomplished by biopsy, patch test, or Wood light.

Question 38

38. During a routine examination of a client’s fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?
    A. Splinter hemorrhage
    B. Beau line
    C. Paronychia
    D. Clubbing

Answer 38

ANS: B
Rationale: A Beau line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base

Question 39

39. A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
    A. Vesicle
    B. Macule
    C. Nodule
    D. Wheal

Answer 39

ANS: A
Rationale: A vesicle is a primary skin lesion that is elevated and has fluid contained in the dermis. Examples of vesicles would be a blister or insect bite. Wheals, macules, and nodules are not characterized by elevation and the presence of serous fluid.