Nursing care of adults exam 3
A nurse notes that a 55 year old light skinned patient has dry, flaky skin. Which action by the
patient should alert the nurse to a problem?
1.. The patient always puts a moisturizing lotion on her hands after washing them
2. The patient takes daily showers with soap and hot water
3. The patient takes a daily multiple vitamin
4. The patient spends some time outdoors and uses sunscreen every 1.5 to 2 hours. - ANS 2
A nurse is teaching teenagers regarding the importance of protecting the skin from UV rays.
What information should the nurse include? (Select all that apply.)
1. Use a sunscreen with a sun protection factor (SPF) of at least 30.
2. Apply sunscreen thinly.
3. Wear light, loose clothing.
4. Gauge exposure while in the sun.5. Wear sunglasses and a hat. - ANS 1,5
A patient with a suspicious skin lesion is scheduled for a punch skin biopsy. What is the most
accurate explanation that the nurse would give about the procedure?
1. "It is shaving a top layer off a lesion that rises above the skin line."
2. "It is removing a core from the center of the lesion."
3. "It is removing the entire lesion."
4. "It is aspirating a tissue sample." - ANS 2
A patient has a rash of unknown origin. Which assessment question(s) would help determine
the underlying cause of the lesion? (Select all that apply.)
1. "When did the rash or lesion first appear?"
2. "Can you think of any event or different food you ate or substance you were using just before
it appeared?"
3. "What drugs are you taking? Do you take any over-the-counter medications?"
4. "Have you ever had radiation therapy?"
5. "Do you have a history of any skin disorders in your family?" - ANS 1,2,3,4,5
What physiologic changes in aging predispose older adults to skin breakdown? (Select all that
apply.)
1. Thickening of skin
2. Loss of collagen
3. Increased elastic fibers
4. Decreased adipose tissues
5. Reduced sebaceous gland activity - ANS 2,4,5
A nurse needs to apply a dressing to a patient who has fragile skin. Which intervention would
the nurse use to protect the patient from skin tears?
, 1. Ask the provider to give specific orders for wound care.
2. Gently clean and apply a sterile transparent dressing.
3. Tape the dressing with paper tape and prevent tension.
4. Allow any tape and gauze dressing materials to fall off naturally. - ANS 3
A nurse is observing a nursing assistant provide skin care to an older adult patient. Which action
by the nursing assistant indicates a need for further training?
1. Using soap and hot water every day to clean the patient's body
2. Alerting the nurse about a wet dressing
3. Reporting redness and blanching over the sacral area
4. Applying lotion while the skin is still damp - ANS 1
A nurse is supervising a new graduate nurse (GN) who is examining a new patient with skin
lesions. The nurse would intervene if the GN:
1. gently handles the patient's extremities to prevent skin tears.
2. observes the condition of the skin and measures the size of the lesions.
3. removes the scales and crusts from the lesions to clean the skin.
4. assesses for and documents any home remedies that the patient has tried. - ANS 3
A nurse is taking care of a 75-year-old man who spends most of his time in bed or sitting. What
steps should be taken to prevent a skin tear? (Select all that apply.)
1. Have the patient wear long sleeves and long pants.
2. Lubricate the patient's skin with cream or lotion twice a day.
3. Massage the skin vigorously, especially over bony prominences.
4. Never use a lift sheet to move or turn the patient.
5. Pad bed rails, wheelchair arms, leg supports, or other equipment where the patient may
bump an extremity. - ANS 1,2,5
A nurse reads in a patient's record that the provider observed "circumscribed, superficial
vesicles with a collection of serous fluid." The nurse anticipates that the provider will make
which recommendation for the patient?
1. A prescription for a topical application for acne
2. Isolation precautions for herpes zoster
3. Over-the-counter antihistamine for an insect bite
4. Patient education to self-monitor the wart - ANS 2
In managing dermatitis, the nurse should provide which instructions? (SATA)
1. Avoid the allergen or irritant
2. Provide adequate skin lubrication
3. wash skin frequently with germicidal soaps
4. Maintain skin moisture
5.Apply steroid based preparations - ANS 1,2,4,5
A nurse notes that a 55 year old light skinned patient has dry, flaky skin. Which action by the
patient should alert the nurse to a problem?
1.. The patient always puts a moisturizing lotion on her hands after washing them
2. The patient takes daily showers with soap and hot water
3. The patient takes a daily multiple vitamin
4. The patient spends some time outdoors and uses sunscreen every 1.5 to 2 hours. - ANS 2
A nurse is teaching teenagers regarding the importance of protecting the skin from UV rays.
What information should the nurse include? (Select all that apply.)
1. Use a sunscreen with a sun protection factor (SPF) of at least 30.
2. Apply sunscreen thinly.
3. Wear light, loose clothing.
4. Gauge exposure while in the sun.5. Wear sunglasses and a hat. - ANS 1,5
A patient with a suspicious skin lesion is scheduled for a punch skin biopsy. What is the most
accurate explanation that the nurse would give about the procedure?
1. "It is shaving a top layer off a lesion that rises above the skin line."
2. "It is removing a core from the center of the lesion."
3. "It is removing the entire lesion."
4. "It is aspirating a tissue sample." - ANS 2
A patient has a rash of unknown origin. Which assessment question(s) would help determine
the underlying cause of the lesion? (Select all that apply.)
1. "When did the rash or lesion first appear?"
2. "Can you think of any event or different food you ate or substance you were using just before
it appeared?"
3. "What drugs are you taking? Do you take any over-the-counter medications?"
4. "Have you ever had radiation therapy?"
5. "Do you have a history of any skin disorders in your family?" - ANS 1,2,3,4,5
What physiologic changes in aging predispose older adults to skin breakdown? (Select all that
apply.)
1. Thickening of skin
2. Loss of collagen
3. Increased elastic fibers
4. Decreased adipose tissues
5. Reduced sebaceous gland activity - ANS 2,4,5
A nurse needs to apply a dressing to a patient who has fragile skin. Which intervention would
the nurse use to protect the patient from skin tears?
, 1. Ask the provider to give specific orders for wound care.
2. Gently clean and apply a sterile transparent dressing.
3. Tape the dressing with paper tape and prevent tension.
4. Allow any tape and gauze dressing materials to fall off naturally. - ANS 3
A nurse is observing a nursing assistant provide skin care to an older adult patient. Which action
by the nursing assistant indicates a need for further training?
1. Using soap and hot water every day to clean the patient's body
2. Alerting the nurse about a wet dressing
3. Reporting redness and blanching over the sacral area
4. Applying lotion while the skin is still damp - ANS 1
A nurse is supervising a new graduate nurse (GN) who is examining a new patient with skin
lesions. The nurse would intervene if the GN:
1. gently handles the patient's extremities to prevent skin tears.
2. observes the condition of the skin and measures the size of the lesions.
3. removes the scales and crusts from the lesions to clean the skin.
4. assesses for and documents any home remedies that the patient has tried. - ANS 3
A nurse is taking care of a 75-year-old man who spends most of his time in bed or sitting. What
steps should be taken to prevent a skin tear? (Select all that apply.)
1. Have the patient wear long sleeves and long pants.
2. Lubricate the patient's skin with cream or lotion twice a day.
3. Massage the skin vigorously, especially over bony prominences.
4. Never use a lift sheet to move or turn the patient.
5. Pad bed rails, wheelchair arms, leg supports, or other equipment where the patient may
bump an extremity. - ANS 1,2,5
A nurse reads in a patient's record that the provider observed "circumscribed, superficial
vesicles with a collection of serous fluid." The nurse anticipates that the provider will make
which recommendation for the patient?
1. A prescription for a topical application for acne
2. Isolation precautions for herpes zoster
3. Over-the-counter antihistamine for an insect bite
4. Patient education to self-monitor the wart - ANS 2
In managing dermatitis, the nurse should provide which instructions? (SATA)
1. Avoid the allergen or irritant
2. Provide adequate skin lubrication
3. wash skin frequently with germicidal soaps
4. Maintain skin moisture
5.Apply steroid based preparations - ANS 1,2,4,5
