Chapter 50

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Chapter 50: 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. “Don’t 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 noth- ing 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
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4. The daughter of an older adult patient who has just returned from surgery is distressed about her father’s pale, cold hands and feet. The nurse covers the patient with an extra blanket and responds: 1. “Don’t 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 tem- porarily, making for cold extremities.” 4. “We are watching the disturbed circulation in your dad’s hands and feet very care- fully.” 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: 1 DIF: Cognitive Level: Comprehension REF: 1122-1123 OBJ: 1 TOP: Skin Blood Reservoir KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. When assessing the capillary refill, the nurse may document as normal a refill time of: 1. 3 seconds. 2.
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