Integumentary Management

1. A nurse is assessing a patient’s skin for signs of dehydration. Which finding would indicate dehydration? A) Warm, dry skin B) Moist, cool skin C) Elastic skin turgor D) Pale, clammy skin Answer: A) Warm, dry skin Rationale: Dehydrated skin is often warm and dry due to decreased moisture content and impaired blood flow. ________________________________________ 2. A patient presents with a rash that is raised, red, and itchy. What type of skin lesion is most likely present? A) Macule B) Papule C) Plaque D) Vesicle Answer: B) Papule Rationale: Papules are small, raised lesions that can be red and itchy, often seen in allergic reactions or other dermatological conditions. ________________________________________ 3. Which of the following findings should alert the nurse to the possibility of a pressure ulcer? A) Pale skin B) Redness over a bony prominence that blanches C) Warmth and swelling of the skin D) A deep, open wound Answer: A) Pale skin Rationale: Pale skin can indicate compromised blood flow, which is a risk factor for developing pressure ulcers. ________________________________________ 4. The nurse is educating a patient about how to perform skin self-examinations. Which instruction is most important? A) Examine the skin under bright sunlight. B) Report any changes in moles or new growths. C) Avoid touching any lesions. D) Use a magnifying glass for better visualization. Answer: B) Report any changes in moles or new growths. Rationale: It is crucial for patients to report changes in their skin, as these can be indicators of malignancy. ________________________________________ 5. A patient with a history of skin cancer asks about the use of sunscreen. What is the nurse's best response? A) "Use a sunscreen with at least SPF 15." B) "You don’t need sunscreen if you’re not outdoors." C) "Sunscreen should be applied only once a day." D) "A higher SPF offers better protection." Answer: D) "A higher SPF offers better protection." Rationale: Higher SPF provides greater protection against harmful UV rays, which is particularly important for individuals with a history of skin cancer. ________________________________________ 6. When teaching about the signs of infection in a wound, which symptom should the nurse emphasize? A) Increased drainage B) Edema C) Redness around the wound D) Fever Answer: D) Fever Rationale: A fever is a systemic sign of infection and indicates that the body is fighting an infection, necessitating further assessment. ________________________________________ 7. A patient is diagnosed with shingles. What teaching point should the nurse include? A) Shingles is contagious, and you should avoid contact with others. B) The rash will resolve in 1-2 days. C) Once you have shingles, you can’t get it again. D) Antiviral medication is not necessary for shingles. Answer: A) Shingles is contagious, and you should avoid contact with others. Rationale: Shingles can spread to those who have not had chickenpox; therefore, precautions should be taken. ________________________________________ 8. Which assessment finding would indicate that a patient has developed a stage II pressure ulcer? A) A non-blanchable erythema B) A shallow open ulcer with a red-pink wound bed C) Full thickness tissue loss D) A deep tissue injury Answer: B) A shallow open ulcer with a red-pink wound bed Rationale: A stage II pressure ulcer presents as a shallow open ulcer with a red-pink wound bed and may include serous drainage. ________________________________________ 9. The nurse is caring for a patient with a burn. Which is the priority nursing diagnosis? A) Impaired skin integrity B) Risk for infection C) Acute pain D) Impaired mobility Answer: B) Risk for infection Rationale: Following a burn, the skin barrier is compromised, increasing the risk of infection, which is a priority concern. ________________________________________ 10. A patient with psoriasis is experiencing a flare-up. What should the nurse recommend to manage symptoms? A) Daily use of a thick moisturizer B) Avoidance of all sunlight C) Frequent hot baths D) Use of alcohol-based skin products Answer: A) Daily use of a thick moisturizer Rationale: Moisturizers help alleviate dryness and reduce scaling associated with psoriasis.