Med Surg, Integumentary System

Med Surg, Integumentary System 1. When the nurse is assessing a 42-year-old woman, the patient states that she is using topical fluorouracil (Efudex, Fluoroplex) to treat actinic keratoses on her face. Which additional information will be most important for the nurse to obtain? a. Method of birth control the patient is using b. History of extensive sun exposure by the patient c. Length of time the patient has used the medication d. Appearance of the treated areas on the patients face ANS: A Since fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information also will be obtained by the nurse, but lack of reliable birth control has the most potential for serious adverse medication effects. 2. Which assessment information documented in a patients chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old patient admitted with bacterial pneumonia? a. Scattered macular brown areas on extremities b. Skin brown and wrinkled, skin tenting on forearm c. Longitudinal nail bed ridges noted, sparse scalp hair d. Skin moist and intact; states history of allergic rashes ANS: D Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other response would be normal for an elderly patient. 3. A patient has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. To determine whether the lesion is related to blood vessel dilation, the nurse will a. elevate the patients leg. b. press firmly on the lesion. c. check the temperature of the skin around the lesion. d. palpate the dorsalis pedis and posterior tibial pulses. ANS: B If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion. 4. When examining a homebound patient, the home health nurse notes a musky, sour body odor. Based on this assessment, the most appropriate nursing action is to a. teach the patient to apply a moisturizing body lotion daily. b. ask about use of over-the-counter (OTC) skin medications. c. ask the health care provider about a prescription for a topical antifungal. d. schedule nursing assistive personnel to help with bathing several times weekly. ANS: D The skin odor indicates that the patients hygiene is poor and that assistance with bathing is needed. Although elderly patients may need moisturizing lotions and should be asked about use of skin medications, the assessment data do not indicate that these are the most appropriate actions. An antifungal would be indicated if the nurse noticed a yeast odor. 5. A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine whether the patient is cyanotic, the nurse will a. assess the skin color of the earlobes. b. apply pressure to the palms of the hands. c. check the lips and oral mucous membranes. d. examine capillary refill time of the nail beds. ANS: C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation, but not for skin color. 6. The nurse is preparing to obtain a culture from a patient who has a possible fungal infection in the groin area. Which action is appropriate? a. Apply a topical anesthetic before obtaining the culture. b. Use sterile gloves to squeeze the lesion and obtain exudate. c. Swab the infected area with a sterile cotton-tipped applicator. d. Scrape the area gently with a razor blade to obtain a specimen. ANS: C Fungal cultures are obtained by swabbing the affected area of the skin. The other actions might be used for obtaining other types of specimens. 7. The nurse notes several angiomas on the legs of a 73-year-old patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Educate the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist. ANS: A Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment. 8. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse will plan to teach the patient about a. shave biopsy. b. punch biopsy. c. incisional biopsy. d. excisional biopsy. ANS: C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant; a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face. 9. During assessment of the patients skin, the nurse observes a ring of small, raised, discrete lesions filled with serous fluid on the patients right temple. When documenting the lesions, the nurse will describe the lesions as a. grouped. b. confluent. c. zosteriform. d. generalized. ANS: A The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions. 10. A patient reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for a. skin atrophy. b. lichenification. c. skin varicosity. d. keloid formation. ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities. 11. The nurse notes these abnormalities on the skin of a 95-year-old patient who is being admitted to an assisted living facility. Which abnormality is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen ANS: D Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patients health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action. 12. When taking the health history for a patient, the nurse discovers that the patient works as a roofer. The nurse will plan to teach the patient about how to self-assess for clinical manifestations of (select all that apply) a. alopecia. b. intertrigo. c. wrinkling. d. erythema. e. actinic keratosis. ANS: C, D, E A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure. Chapter 23 1. To decrease the risk for sun damage to the skin, which information should the nurse include when teaching patients? a. Waterproof sunscreens will provide good protection when swimming. b. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. c. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time). d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. ANS: C The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. The term waterproof is misleading; no sunscreen is completely waterproof. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased. 2. Which information should the nurse include when teaching a patient who has just received a prescription for sulfamethoxazole and trimethoprim (Septra, Bactrim) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking sulfamethoxazole. ANS: A The patient should wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate. 3. A patient is diagnosed with basal cell carcinoma (BCC) of the face. Which information should be included in patient teaching? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Low dose systemic chemotherapy is used to treat BCC. d. Minimizing sun exposure will reduce risk for future BCC. ANS: D BCC is frequently associated with sun exposure. BCC spread locally, but do not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local chemotherapy may be used to treat BCC. 4. A patient in the dermatology clinic has a small, slow-growing papule with ulceration and a depression in the center of the lesion on the right cheek. The nurse will anticipate the need to a. prepare the patient for a biopsy. b. teach about the use of corticosteroid creams. c. educate the patient about use of tretinoin (Retin-A). d. discuss the need for topical application of antibiotics. ANS: A Because the appearance of the lesion is consistent with a possible basal cell carcinoma (BCC), the appropriate treatment would be excision and biopsy. Over-the-counter (OTC) corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion unless the biopsy indicated that the lesion was nonmalignant. 5. After the nurse determines that a patient has the following risk factors for melanoma, which risk factor should be the focus of patient teaching related to prevention? a. The patient has multiple dysplastic nevi. b. The patient is fair-skinned and has blue eyes. c. The patients mother died of a malignant melanoma. d. The patient uses a tanning booth throughout the winter. ANS: D Since the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk. 6. The health care provider diagnoses impetigo for a patient who has crusty vesicopustular lesions on the lower face. Which topic will be included in the teaching plan for this patient? a. Avoidance of antibiotic ointments on the lesions b. How to clean the infected areas with soap and water c. Use of petroleum jelly (Vaseline) to soften crusty areas d. Appropriate use of alcohol-based cleansers on the lesions ANS: B The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-andwater removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments may be applied to the lesions. 7. When examining a patients oral cavity, the nurse notes the presence of white lesions that resemble milk curds at the back of the throat. Which question by the nurse is appropriate at this time? a. Do you have a productive cough? b. How often do you brush your teeth? c. Are you taking any medications at present? d. Have you ever had an oral herpes infection? ANS: C The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection. 8. When examining a patients scalp, the nurse suspects the presence of pediculosis on finding a. ringlike rashes with red, scaly borders over the entire scalp. b. papular, wheal-like lesions with white deposits on the hair shaft. c. patchy areas of alopecia with small vesicles and excoriated areas. d. red, hivelike papules and plaques with sharply circumscribed borders. ANS: B Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders. 9. The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the nose. Which information will the nurse include in the patient teaching plan? a. You may develop nausea and anorexia, but good nutrition is important during treatment. b. You will need to avoid crowds because of the risk for infection caused by chemotherapy. c. The nose will develop painful, eroded areas that will take weeks before completely healing. d. 5-FU is needed to shrink the lesion so that less scarring occurs once the lesion is excised. ANS: C Topical 5-FU causes an initial reaction of erythema, itching, and erosion, which lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea. Actinic keratosis is not usually treated with excision. 10. A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. Which finding by the nurse indicates a possible adverse effect of the medication? a. Thinning of the affected skin b. Alopecia of the affected areas c. Reddish-brown discoloration of the skin d. Dryness and scaling in the areas of treatment ANS: A Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness/scaling of the skin are not adverse effects of topical corticosteroid use. 11. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. To minimize complications from this procedure, the nurse plans to a. cleanse the skin carefully with an antiseptic soap. b. shield any unaffected areas with lead-lined drapes. c. have the patient use protective eyewear while receiving PUVA. d. apply petroleum jelly to the areas surrounding the psoriatic lesions. ANS: C The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage. 12. A patient with an enlarging, irregular mole that is 6 mm in diameter is scheduled for outpatient treatment. The nurse should plan on teaching the patient about a. curettage. b. cryosurgery. c. punch biopsy. d. surgical excision. ANS: D The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and cryosurgery are not used if malignancy is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter. 13. Which information will the nurse include when teaching a 70-year-old patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and shampoo daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection. ANS: C Warm water and moisturizing soap will avoid overdrying the skin. Since older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in. 14. Which action will the nurse take when applying a wet dressing to an inflamed and pruritic area of skin on a patients ankle? a. Use a cool solution to wet the dressing. b. Change the dressing using sterile gloves. c. Soak the dressing in sterile normal saline. d. Apply the dressing from the knee to the foot. ANS: A Cool solutions are used when wet dressings are applied to inflamed areas. Wet dressings do not require sterile technique; tap water is the most common solution used. To avoid maceration of healthy skin, wet dressings should only be applied over the affected area. 15. Through interviewing a patient who has a history of contact dermatitis, the nurse obtains this information about over-the-counter (OTC) medication use. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to any pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs. ANS: B Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient. 16. The nurse notes darker skin pigmentation in the skinfolds of a patient who has a body mass index of 40 kg/m2. Which action should the nurse take? a. Teach the patient about the risk for type 2 diabetes. b. Educate the patient about treatment of fungal infection. c. Discuss the use of drying agents to minimize infection risk. d. Instruct the patient about use of mild soap to clean skinfolds. ANS: A The presence of acanthosis nigricans in skinfolds suggests an increased risk for type 2 diabetes. The description of the patients skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better. 17. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. Which action is best for the nurse to take at this time? a. Instruct the patient about the importance of nutrition in skin heath. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin. ANS: C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patients dry skin, and referral to a podiatrist also may be needed, but the priority is to rule out underlying disease that may be causing these manifestations. 18. After a patient with a squamous cell carcinoma (SCC) has a Mohs procedure in the dermatology clinic, which nursing action will be included in the postoperative plan of care? a. Describe the use of topical fluorouracil on the incision. b. Teach how to use sterile technique to clean the suture line. c. Schedule daily appointments for wet-to-dry dressing changes. d. Educate about use of cold packs to reduce bruising and swelling. ANS: D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Since the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. The suture line is cleaned with tap water. No debridement with wet-to-dry dressings is indicated. 19. A patient with atopic dermatitis has a new prescription for tacrolimus (Protopic). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. After I apply the medication, I can go ahead and get dressed as usual. b. I will rub the medication gently onto the skin every morning and night. c. I will need to minimize my time in the sun while I am using the Protopic. d. If the medication burns when I apply it, I will wipe it off and call the doctor. ANS: D The patient should be taught that transient burning at the application site is an expected effect of tacrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective. 20. After the nurse has finished teaching a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg, which patient action indicates that more teaching is needed? a. The patient spreads the cream using a downward motion. b. The patient takes a tepid bath before applying the cream. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream. ANS: C Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful. 21. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) who are assisting with the care of a patient with furunculosis? a. Applying antibiotic cream to the groin. b. Obtaining cultures from ruptured lesions. c. Evaluating the patients personal hygiene. d. Cleaning the skin with antimicrobial soap. ANS: D Cleaning the skin is within the education and scope of practice for NAP. Administration of medication, obtaining cultures, and evaluation are higher-level skills that require the education and scope of practice of licensed nursing personnel. 22. The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority? a. The patient complains of incisional pain. b. The patients heart rate is 110 beats/minute. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated. ANS: D Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action.. A heart rate of 110 may be related to the stress associated with surgery; assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling. 23. A patient who has severe refractory psoriasis on the face, neck, and extremities has quit working and withdrawn from social activities because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of enrolling in a worker-retraining program. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life. ANS: D The nurses initial actions should be to assess the impact of the disease on the patients life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate. 1. When teaching a patient with contact dermatitis of the arms and lower legs about ways to decrease pruritis, which information will the nurse include (select all that apply)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine with sedative effects can reduce scratching. ANS: A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bathwater is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.