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50: Chapter Skin Disorders
MULTIPLE CHOICE 1. Displaying her hands, a patient asks, Do you think my liver is OK? Look at all these liver spots! The most appropriate response would be: 1. The spots could mean there is something wrong; I will make a note of it. 2. The spots are normal aging changes and have nothing to do with your liver. 3. Have you recently been exposed to hepatitis? 4. Dont worry about them. They will fade during the winter. ANS: 2 Lentigines on sun-exposed areas are called liver spots because of their color, but have nothing to do with the liver or any disease process. They are normal changes of aging. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1123 OBJ: 3 TOP: Liver Spots KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. A confused patient who has been restrained because of combativeness and hyperactivity might, because of the restraints, display: 1. lentigines. 2. senile purpura. 3. senile angiomas. 4. seborrheic keratoses. ANS: 2 Purpura are purple bruises that resolve very slowly and are usually the result of minor trauma. PTS: 1 DIF: Cognitive Level: Application REF: 1123 OBJ: 3 TOP: Senile Purpura KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. In taking the functional assessment of a patient with a skin disorder, the nurse will inquire about: 1. a sore that is slow to heal. 2. unusual hair growth. 3. previous skin disorders. 4. exposure to chemicals or irritants. ANS: 4 The functional assessment is a search for clues in the occupation and lifestyle of the patient. Options 1, 2, and 3 all reference medical history and system review. PTS: 1 DIF: Cognitive Level: Application REF: 1124 OBJ: 5 TOP: Functional Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The daughter of an older adult patient who has just returned from surgery is distressed about her fathers pale, cold hands and feet. The nurse covers the patient with an extra blanket and responds: 1. Dont be concerned. It is quite cold in the operating room. Your dad will be warm in a minute. 2. Older patients like your dad get a little shocky during surgery. 3. When patients have blood loss during surgery, superficial vessels close off temporarily, making for cold extremities. 4. We are watching the disturbed circulation in your dads hands and feet very carefully. ANS: 3 The 10% of the blood network that is in the skin can be reduced by constriction and shunted to the vital organs. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 1 TOP: Skin Blood Reservoir Nursing Process Step: Implementation NCLEX: Psychosocial Integrity REF: 1122-1123
5. When assessing the capillary refill, the nurse may document as normal a refill time of: 1. 3 seconds. 2. 5 seconds. 3. 6 seconds. 4. 8 seconds. ANS: 1 Capillary refill is a method of quick assessment of perfusion to the extremities. A normal capillary refill time is 3 seconds or less. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1123 OBJ: 2 TOP: Capillary Refill KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse instructs a patient with vitiligo who is receiving phototherapy to: 1. expose himself to the sun for several hours before treatment to acclimate the skin surface. 2. wear protective clothing. 3. wear loose clothing such as sleeveless T shirts and shorts after the treatment. 4. leave sunglasses off after treatment so that the eyes can more quickly accommodate. ANS: 2 Eight hours before and after each treatment the patient should wear protective clothing, sunglasses, and sunscreen to decrease added UV exposure from other sources. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 6 TOP: Phototherapy Nursing Process Step: Implementation NCLEX: Safe, Effective Care Environment REF: 1128
7. A nurse screening patients that the plastic surgeon is considering for phototherapy would exclude: 1. a 34-year-old woman with lupus erythematosus. 2. a 5-year-old child with pneumonia. 3. a 60-year-old man with a pacemaker. 4. a 23-year-old woman who is 3 months pregnant. ANS: 1 Persons with lupus should avoid exposure to ultraviolet (UV) light. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 6 TOP: Phototherapy Nursing Process Step: Assessment NCLEX: Health Promotion and Maintenance REF: 1128
8. The implementation that the nurse may perform for a patient with pruritus without a physicians order is to: 1. apply topical corticosteroids to affected areas. 2. administer an antihistamine. 3. apply lubricant to unbroken skin. 4. bathe the patient in an oatmeal bath. ANS: 3 Application of a lotion or lubricant to unbroken skin may be done without an order. PTS: 1 DIF: Cognitive Level: Application REF: 1132 OBJ: 5 TOP: Pruritus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The implementation that would make a patient with atopic dermatitis more comfortable is to: 1. instruct the patient to wear loose clothing. 2. add alcohol to the bath water. 3. provide a diet low in fat. 4. increase the room temperature to 78 F to 80 F. ANS: 1 Loose clothing and a cool atmosphere allow the skin to stay cool and reduce sweating. Alcohol is drying to the skin. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 7 TOP: Atopic Dermatitis Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 1133
10. The sign or symptom that suggests that a patient with impaired skin integrity is developing a systemic infection is: 1. a lesion on the patients leg that is swollen and warm to the touch. 2. a temperature that has risen to 101 F.
3. blood pressure that has risen from 126/84 to 130/86. 4. a request by the patient for medication for severe itching. ANS: 2 Rise in temperature is a systemic response. Normal blood pressure, warmth, swelling, and itching are not evidence. PTS: REF: TOP: MSC: 1 DIF: Cognitive Level: Application 1138, Nursing Care Plan OBJ: 2 Systemic Infection KEY: Nursing Process Step: Assessment NCLEX: Physiological Integrity
11. An appropriate implementation for a patient with severe psoriasis who has a nursing diagnosis of Disturbed body image related to skin lesions would be: 1. touching the patient often. 2. reassuring the patient of a quick remission. 3. reminding the patient to bathe often. 4. prompt administration of PRN medications. ANS: 1 To touch, interact, and care for a disfigured patient attentively role-models acceptance. PTS: REF: KEY: MSC: 1 DIF: Cognitive Level: Application 1138, Nursing Care Plan OBJ: 1 Nursing Process Step: Implementation NCLEX: Psychosocial Integrity TOP: Psoriasis
12. A patient with severe psoriasis who is to be treated with a systemic drug, methotrexate, anxiously asks, Is this drug safe? Are there some side effects I need to know about? The nurses best response would be: 1. Yes, it is used to treat cancer and psoriasis, but it has no severe side effects. 2. No, it is not a cancer drug, but you should ask your physician about concerns regarding your therapy. 3. We use the drug with many kinds of patients, including cancer patients. You will have periodic blood tests. 4. I dont know if it is used with cancer patients or not, but the drug can be used when conditions are as severe as yours. ANS: 3 Methotrexate is an immunosuppressive drug used to treat psoriasis that is nonresponsive to other protocols. Periodic blood tests are done to assess for leukopenia. Options 1 and 2 are erroneous information. Option 4 does not answer the patients question. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 6 TOP: Methotrexate Sodium Nursing Process Step: Implementation NCLEX: Psychosocial Integrity REF: 1134-1135
13. A family member of a patient with severe dermatitis says, I was always so careful to bathe him every day. I guess I just wasnt careful enough. The nurses best response would be:
1. 2. 3. 4.
Dermatitis is not caused by poor hygiene. Dont worry; we will bathe him thoroughly while he is here. You will have a chance to do better when he is back at home. You shouldnt feel like the skin condition is your fault.
ANS: 1 Dermatitis is not a condition of poor hygiene. Options 2, 3, and 4 are belittling responses and are not therapeutic. PTS: 1 DIF: Cognitive Level: Analysis REF: 1132 OBJ: 1 TOP: Dermatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. When caring for a long-term bedridden obese who patient has a nursing diagnosis of Risk for infection related to obesity, the nurse should assess for the moist red lesions of Candida albicans, especially on the: 1. scalp, behind the ears. 2. abdominal skin folds. 3. shaft of the penis. 4. sacrum and bony prominences. ANS: 2 C. albicans appears most often in skin folds. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 2 TOP: Yeast Infection Nursing Process Step: Assessment NCLEX: Health Promotion and Maintenance REF: 1136
15. Information essential for the nurse to gather when interviewing a young woman who is taking the drug Accutane (isotretinoin) for acne is which of the following? 1. Usual weight 2. Family history of breast cancer 3. Current method of birth control 4. Drugs previously used ANS: 3 Accutane can cause severe fetal deformities. PTS: REF: KEY: MSC: 1 DIF: Cognitive Level: Application 1131, Drug Therapy table OBJ: 6 Nursing Process Step: Assessment NCLEX: Safe, Effective Care Environment TOP: Acne Treatment
16. An excited mother of a teenage boy with severe acne furiously reports to the nurse, Ive told him a thousand times he should bathe more often! Ive kept after him about all that junk food he eats. I jump on him when I see him squeezing his zits. I tried to get him to scrub his face three times a day! The complaint the nurse recognizes as a true statement about the cause of acne is: 1. poor personal hygiene.
2. ingestion of junk food. 3. squeezing lesions. 4. need for facial scrubs. ANS: 3 Squeezing the lesions may cause them to spread and push the infection deeper into the follicles. Options 1, 2, and 4 are myths. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1139 OBJ: 8 TOP: Acne KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 17. A patient who has undergone treatment for herpes simplex virus type 2 (HSV 2) expresses relief that she is cured. The nurse should include in her teaching: 1. the need for daily douches of Burows solution. 2. that HSV is permanently cured by acyclovir (Zovirax). 3. sexual partners are now safe from infection from her. 4. that HSV lies dormant and can be triggered without any sexual contact. ANS: 4 The virus goes dormant but can recur. Herpes is always present. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 7 TOP: Herpes Simplex Nursing Process Step: Planning NCLEX: Health Promotion and Maintenance REF: 1139
18. When an 80-year-old patient comes to the emergency department with extreme pain and itching in the hip and leg, and has herpetic vesicular lesions on the left hip, the nurse inquires about the exposure to: 1. herpes simplex type 1. 2. herpes simplex type 2. 3. smallpox. 4. chickenpox. ANS: 4 Chickenpox is a virus that lies latent in the neural sheath and can be activated as shingles in older adults. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1140 OBJ: 7 TOP: Herpes Zoster KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The physician asks the nurse to take a smear from herpetic lesions in an older patients hip to diagnose the disorder. The nurse recognizes that the probable test that will be performed is a: 1. culture and sensitivity to a bactericide. 2. Tzanck smear to test for viral culture. 3. CBC to assess the white blood count for response to a pathogen. 4. titration for the strength of the pathogen.
ANS: 2 The Tzanck test confirms the specific virus. PTS: REF: TOP: MSC: 1 DIF: Cognitive Level: Comprehension 1129, Diagnostic Tests and Procedures table OBJ: 7 Tzanck Smear KEY: Nursing Process Step: Planning NCLEX: Physiological Integrity
20. The nurse organizes the nursing care plan on the nursing diagnosis of Acute pain related to postherpetic neuralgia. The least appropriate implementation would be to: 1. give antiviral medication as prescribed. 2. generously administer pain medication. 3. offer guided imagery or distraction techniques. 4. have the patient ambulate several times daily. ANS: 4 Ambulation certainly is not helpful for the pain. Very little helps the neuralgic pain except direct implementation. PTS: 1 DIF: Cognitive Level: Analysis REF: 1140 OBJ: 7 TOP: Herpes Zoster KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. The nurse explains that the major characteristic that differentiates cutaneous T-cell lymphoma from squamous cell and basal cell carcinomas is that cutaneous T-cell lymphoma: 1. does not metastasize. 2. has a cause unrelated to sun exposure. 3. can be treated with radiation. 4. can be treated topically. ANS: 2 Cutaneous T-cell carcinoma appears in areas protected by the sun. All three neoplasms can metastasize and can be treated by radiation or topically. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 6 TOP: Cutaneous T-Cell Carcinoma Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 1144
22. The nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia, and the fronts of both legs. Using the rule of nines, the nurse would document that the burn size as: 1. 13%. 2. 17%. 3. 25%. 4. 37%. ANS: 4 Per the rule of nines, the front trunk equals 18, the fronts of the legs equal 18, and the genitalia equal 1.
PTS: 1 DIF: Cognitive Level: Application REF: 1144, Figure 50-14 OBJ: 5 TOP: Burn Estimate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. The assessment by the emergency department nurse most indicative that a burn patient might be at risk for respiratory impairment is: 1. burns on the face and neck. 2. respiration of 18. 3. flaring nares. 4. sooty sputum. ANS: 4 Sooty sputum is the most indicative. Facial burns and flaring nares are not conclusive in themselves. Respiration of 18 is normal. PTS: 1 DIF: Cognitive Level: Analysis REF: 1146 OBJ: 5 TOP: Burns: Respiratory Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. In a burn patient with eschar formation around an entire arm, the nurse will include frequent assessment of: 1. urine output. 2. pain level. 3. capillary refill. 4. breath sounds. ANS: 3 Eschar that encompasses a limb can compromise the circulation. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 5 TOP: Eschar: Impaired Circulation Nursing Process Step: Planning NCLEX: Safe, Effective Care Environment REF: 1151
25. During the first 24 hours postburn, fluid replacement is the treatment priority. The assessment that would alert the nurse that the fluid protocol is ineffective is: 1. rectal temperature of 101 F. 2. urine output of 20 mL/hour. 3. crackles in the lower left lobe. 4. marked edema in the burn area. ANS: 2 Decreased urinary output indicates that there is still poor perfusion to the kidney. Temperature elevation and edema are to be expected. Crackles in a dormant patient are not a cause for alarm. PTS: 1 DIF: Cognitive Level: Analysis OBJ: 5 TOP: Burns: Fluid Replacement KEY: Nursing Process Step: Assessment REF: 1150
MSC: NCLEX: Safe, Effective Care Environment MULTIPLE RESPONSE 1. In performing a physical assessment on an 80-year-old man, the nurse anticipates that the age-related skin changes will be (select all that apply): 1. increased nasal hair. 2. flattened nails. 3. small macular lesions at the hairline. 4. increased hair on the helix of the ear. 5. presence of seborrheic keratosis. ANS: 1, 2, 4, 5 Increased hair in the nostrils and ear, flattened discolored nails, and seborrheic keratosis are common age-related skin changes. Macular lesions are abnormal PTS: 1 DIF: Cognitive Level: Application REF: 1123-1124 OBJ: 3 TOP: Age-Related Skin Changes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. The nurse collecting tissue for a Tzanck smear will (place the steps in sequence): 1. open the lesion with a hypodermic needle. 2. place the specimen in culture tube and take to the laboratory. 3. saturate the sterile swab with exudates. 4. wash the lesion. 5. place a pressure dressing on the lesion. ANS: 4, 1, 3, 2 The nurse would wash the lesion, puncture the lesion with a needle, saturate a sterile cotton swab, place it in a culture tube, and take to the laboratory. There is no need for a pressure dressing. PTS: REF: TOP: MSC: 1 DIF: Cognitive Level: Application 1129, Diagnostic Tests and Procedures table OBJ: 4 Tzanck Smear KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity