SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
1) In planning care for the client with psoriasis, the nurse understands that which represents a priority client
problem?
✓ Altered body image
2) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse
should plan to assess which part of the integumentary system first?
✓ Nails
3) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the
health record most accurately using which term?
✓ Ecchymosis
4) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final
coverage of the client's burn wound?
✓ Autograft
5) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV)
light therapy. Which statement would be most appropriate for the nurse to include in the client's
instructions?
6) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and
symptoms should the nurse look for?
✓ Lesions with well-defined geometric margins
7) The nurse is providing home care instructions to the client who just had surgery for squamous cell
carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which
characteristics of this type of skin carcinoma?
✓ Firm, nodular lesion topped with a crust or with a central area of ulceration
8) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate
that teaching was successful? Select all that apply.
✓ "I have to avoid excessive exposure to sunlight."
✓ "I am at higher risk for skin cancer because my mother had one."
9) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment
on which structures? Select all that apply.
✓ Lips
✓ Conjunctiva
✓ Mucous membranes
10) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is
expected from the chemotherapeutic agent. Which statement made by the client indicates a need for
further teaching?
✓ "I can't believe my hair loss will be permanent."
11) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the
body. Which finding suggests that an escharotomy may be necessary?
,SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ High pressure alarm keeps sounding on the ventilator
12) A client with chloasma is extremely stressed about the change in her facial appearance. Which
integumentary change observed by the nurse is consistent with this problem?
✓ Blotchy brown macules across the cheeks and forehead
13) The nurse is planning care for a client who suffered a burn injury and has a negative self-image
related to keloid formation at the burn site. The keloid formation is indicative of which condition?
✓ Hypertrophy of collagen fibers
14) The nurse observes the client's sacrum and notes the following. How will the nurse document this
in the client's medical record? Refer to figure.
View Figure
✓ Stage IV pressure ulcer
15) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous
fistula for access. The client asks the nurse what complications can occur with the access site. What
complications should the nurse inform the client about? Select all that apply.
✓ Hepatitis
✓ Infection
16) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions.
Which statement by the client indicates understanding of the discharge instructions?
✓ "I need to assess my skin for lesions that appear net-like."
17) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible
for this finding? Select all that apply.
✓ Fever
,SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ Vasodilation
✓ Inflammation
✓ Excessively high environmental temperature
18) An older client's physical examination reveals the presence of a fiery star-shaped marking with a
circular, solid center. The nurse recognizes that these findings, which are caused by capillary
radiations extending from the central arterial body, are representative of which lesions?
✓ Spider angioma
19) An older client is lying in a supine position. The nurse understands that the client is at least risk for
skin breakdown in which body area?
✓ Greater trochanter
, SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ "You will need to wear dark eye goggles during the treatment."
20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy
of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select
all that apply.
✓ Obtain an informed consent.
✓ Prepare to apply direct pressure to the biopsy site after the procedure.
✓ Tell the client that a small piece of tissue will be removed for
examination.
21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The
nurse develops the plan based on which characteristics associated with acne? Select all that apply.
✓ The exact cause of acne is unknown.
✓ Acne requires active treatment for control until it resolves.
✓ Oily skin and a genetic predisposition may be contributing factors for
acne.
✓ The types of lesions in acne include comedones (open and closed),
pustules, papules, and nodules.
22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The
nurse determines that which client is at the greatest risk for development of an integumentary disorder?
✓ An outdoor construction worker
23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is.
Which statement is the appropriate response by the nurse?
✓ "The local anesthetic may cause a burning or stinging
sensation."
24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this
procedure?
NCLEX THREE (Recovered).doc
1) In planning care for the client with psoriasis, the nurse understands that which represents a priority client
problem?
✓ Altered body image
2) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse
should plan to assess which part of the integumentary system first?
✓ Nails
3) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the
health record most accurately using which term?
✓ Ecchymosis
4) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final
coverage of the client's burn wound?
✓ Autograft
5) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV)
light therapy. Which statement would be most appropriate for the nurse to include in the client's
instructions?
6) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and
symptoms should the nurse look for?
✓ Lesions with well-defined geometric margins
7) The nurse is providing home care instructions to the client who just had surgery for squamous cell
carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which
characteristics of this type of skin carcinoma?
✓ Firm, nodular lesion topped with a crust or with a central area of ulceration
8) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate
that teaching was successful? Select all that apply.
✓ "I have to avoid excessive exposure to sunlight."
✓ "I am at higher risk for skin cancer because my mother had one."
9) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment
on which structures? Select all that apply.
✓ Lips
✓ Conjunctiva
✓ Mucous membranes
10) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is
expected from the chemotherapeutic agent. Which statement made by the client indicates a need for
further teaching?
✓ "I can't believe my hair loss will be permanent."
11) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the
body. Which finding suggests that an escharotomy may be necessary?
,SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ High pressure alarm keeps sounding on the ventilator
12) A client with chloasma is extremely stressed about the change in her facial appearance. Which
integumentary change observed by the nurse is consistent with this problem?
✓ Blotchy brown macules across the cheeks and forehead
13) The nurse is planning care for a client who suffered a burn injury and has a negative self-image
related to keloid formation at the burn site. The keloid formation is indicative of which condition?
✓ Hypertrophy of collagen fibers
14) The nurse observes the client's sacrum and notes the following. How will the nurse document this
in the client's medical record? Refer to figure.
View Figure
✓ Stage IV pressure ulcer
15) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous
fistula for access. The client asks the nurse what complications can occur with the access site. What
complications should the nurse inform the client about? Select all that apply.
✓ Hepatitis
✓ Infection
16) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions.
Which statement by the client indicates understanding of the discharge instructions?
✓ "I need to assess my skin for lesions that appear net-like."
17) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible
for this finding? Select all that apply.
✓ Fever
,SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ Vasodilation
✓ Inflammation
✓ Excessively high environmental temperature
18) An older client's physical examination reveals the presence of a fiery star-shaped marking with a
circular, solid center. The nurse recognizes that these findings, which are caused by capillary
radiations extending from the central arterial body, are representative of which lesions?
✓ Spider angioma
19) An older client is lying in a supine position. The nurse understands that the client is at least risk for
skin breakdown in which body area?
✓ Greater trochanter
, SAUNDERS COMPREHENSIVE REVIEW FOR
NCLEX THREE (Recovered).doc
✓ "You will need to wear dark eye goggles during the treatment."
20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy
of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select
all that apply.
✓ Obtain an informed consent.
✓ Prepare to apply direct pressure to the biopsy site after the procedure.
✓ Tell the client that a small piece of tissue will be removed for
examination.
21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The
nurse develops the plan based on which characteristics associated with acne? Select all that apply.
✓ The exact cause of acne is unknown.
✓ Acne requires active treatment for control until it resolves.
✓ Oily skin and a genetic predisposition may be contributing factors for
acne.
✓ The types of lesions in acne include comedones (open and closed),
pustules, papules, and nodules.
22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The
nurse determines that which client is at the greatest risk for development of an integumentary disorder?
✓ An outdoor construction worker
23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is.
Which statement is the appropriate response by the nurse?
✓ "The local anesthetic may cause a burning or stinging
sensation."
24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this
procedure?
