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Health Assessment and Physical Examination 4th Edition Estes Test Bank

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Health Assessment and Physical Examination 4th Edition Estes Test Bank

ISBN-13: 978-1111319489

ISBN-10: 1111319480

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Health Assessment and Physical Examination 4th Edition Estes Test Bank

ISBN-13: 978-1111319489

ISBN-10: 1111319480

 

 

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Free Nursing Test Questions:

 

CHAPTER 10: SKIN, HAIR, AND NAILS

 

MULTIPLE CHOICE

 

  1. The order of the integumentary system from the outermost layer to the innermost layer is:
a. epidermis, hypodermis, dermis.
b. dermis, subcutaneous tissue, epidermis.
c. epidermis, dermis, subcutaneous tissue.
d. subcutaneous tissue, dermis, epidermis.

 

 

ANS:  C

The skin, also known as the integumentary system, or cutaneous tissue, is the largest organ system of the body. The surface area of the skin covers approximately 20 square feet in the average adult. It is composed of three main layers: the epidermis (the outer layer), the dermis (the second layer), and the subcutaneous tissue, also called the superficial fascia or hypodermis (the inner layer).

 

PTS:   1                    DIF:    Knowledge    REF:   Skin

 

  1. The palms of the hands and soles of the feet have an extra epidermal layer called the:
a. stratum corneum.
b. stratum lucidum.
c. stratum granulosum.
d. stratum spinosum.

 

 

ANS:  B

The epidermis is uniformly thin except on the surfaces that are exposed to friction, such as  the palms of the hands and the soles of the feet. This skin is thicker because of  work and weight bearing. The additional layer on the palmar and plantar surfaces is the stratum lucidum. The deepest layer of the epidermis, the stratum germinativum or basal cell layer, produces new skin cells. The stratum spinosum overlays the stratum germinativum, and here the cells continue to divide and add to the thickness of the epithelium. The stratum granulosum consists of cells displaced from the spinosum layer. The cells in this layer have stopped dividing and begin making large amounts of the protein keratin. Keratin is durable and water-resistant. It not only coats the surface of the skin, but also forms the basic structure of hair, calluses, and nails.

 

PTS:   1                    DIF:    Knowledge    REF:   Epidermis

 

  1. Which skin diseases are found more commonly in light-skinned than in dark-skinned individuals?
a. keloid formation and acne keloidal folliculitis
b. dermatosis papulosa nigra and seborrheic dermatitis
c. squamous and basal cell carcinoma, and actinic keratosis
d. hypopigmented sarcoidosis and granulomatous skin lesions

 

 

ANS:  C

Squamous and basal cell carcinoma, and actinic keratosis are found more commonly in light-skinned than in dark-skinned individuals. The skin diseases in options a, b, and d are found more commonly in dark-skinned than in light-skinned individuals.

 

PTS:   1                    DIF:    Knowledge    REF:   Health History | Race | Light Skinned

 

  1. A patient complaining of pruritus should be assessed for associated signs and symptoms including:
a. rash and edema.
b. coolness and pallor.
c. cyanosis and coolness.
d. ecchymosis and purpura.

 

 

ANS:  A

Pruritus or itching of the skin is associated with the following manifestations: rashes, lesions, edema, angioedema, anaphylaxis, excoriation or ulcers as a result of scratching, lichenification or thickening of the skin, and systemic disease. As a result of scratching the skin due to pruritus, the skin would most likely be warm and red, not pale, cool, or cyanotic. Ecchymosis is a violaceous discoloration, also called a black-and-blue mark. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis. Neither of these is associated with pruritus.

 

PTS:   1                    DIF:    Comprehension

REF:   Pruritus | Associated Manifestations

 

  1. When assessing Ms. D, who complains of a problem with her fingernails, the nurse should specifically question her about a history of:
a. eczema, melanoma, and herpes zoster.
b. psoriasis, fungal infections, and trauma.
c. alopecia, trichotillomania, and chemotherapy.
d. vitiligo and lupus erythematosus.

 

 

ANS:  B

The various components of the past health history are linked to skin, hair, and nail pathology and skin-, hair-, and nail-related information. If a patient has problems with fingernails, the nurse should ask about a history of allergies, psoriasis, bacterial or fungal infections, trauma, brittle nails, nail biting, and congenital anomalies. If a patient has skin-specific problems, the past health history should include asking about allergies, eczema, atopic dermatitis, melanoma, albinism, vitiligo, psoriasis, skin cancer, athlete’s foot, birthmarks, body piercing, tattoos, and urticaria. Lupus erythematosus and herpes zoster are pathologies associated with nonskin specific findings. Alopecia, trichotillomania, and chemotherapy are pathologies associated with hair- and nonhair-specific findings.

 

PTS:   1                    DIF:    Application    REF:   Medical History | Nail Specific

 

  1. Which diseases, reported by Mr. R during his family health history, are familial in nature?
a. cutaneous moniliasis and paronychia
b. pediculosis pubis and tinea capitis
c. psoriasis, brittle nails, and hair loss
d. verruca vulgaris and acne

 

 

ANS:  C

Psoriasis, brittle nails, and hair loss are familial in nature. Cutaneous moniliasis, also known as candidiasis, is a yeast infection. It normally occurs in the moist folds behind the ears, under the breasts, in the axilla, umbilicus, along the inguinal and pudendal regions, and in the gluteal and perineal areas. Paronychia is an infection of the fold of skin at the margin of a nail. Pediculosis pubis is infestation of the pubic hair with lice. Tinea capitis is a superficial fungal infection of the scalp, most commonly seen in children. Verruca vulgaris is a benign viral warty skin lesion caused by a common contagious papovavirus. Acne is a disorder of the face that is common where sebaceous glands are numerous. None of the disorders or diseases in options a, b, and d is familial in nature.

 

PTS:   1                    DIF:    Knowledge    REF:   Family Health History

 

  1. Which skin manifestation caused by substance abuse is related to alcohol abuse?
a. yellow discoloration of the fingertips of one hand
b. telangiectasia (spider veins) on the nose, neck, and upper chest
c. leathery facial appearance
d. bruises between the toes and under the nails

 

 

ANS:  B

Telangiectasia (spider veins) on the nose, neck, and upper chest are skin manifestations caused by alcohol abuse. Yellow discoloration of the fingertips of one hand and leathery facial appearance are related to tobacco use. Skin manifestations related to intravenous drug use include injection tracks or sites, especially prevalent in the forearms, behind the knees, between the toes and fingers, and under the nails.

 

PTS:   1                    DIF:    Comprehension                               REF:   Drug Use

 

Ms. S, a 20-year-old college student, worked for the past four summers as a lifeguard at the community swimming pool. During her assessment, she asks many questions related to the care of her skin and hair.

 

  1. Because Ms. S’s work environment involved daily exposure to sunlight, she is at risk for:
a. contact dermatitis and eczema.
b. rashes, urticaria, and angioedema.
c. basal or squamous cell carcinoma and wrinkles.
d. seborrheic keratosis and acne.

 

 

ANS:  C

A work environment that includes daily exposure to sunlight puts an individual at risk for skin eruptions, increased incidence of basal or squamous cell carcinoma, burns, wrinkles, senile freckles, lightened hair, and excessive exposure to ultraviolet radiation. A work environment involving chemicals can result in contact dermatitis and eczema. Rashes, urticaria, edema, angioedema, and pruritus are skin manifestations associated with working in an environment where one is subject to insect bites. Neither seborrheic keratosis nor acne is associated with sun exposure.

 

PTS:   1                    DIF:    Comprehension                               REF:   Work Environment

 

  1. You ask Ms. S a number of questions so that together you can develop a realistic plan of care for her skin and hair. Which question is the least helpful?
a. Do you wear a hat, visor, long sleeves, or pants in the sun?
b. Do you use a hair dryer, heated curlers, or curling iron?
c. How frequently do you cut your hair?
d. What strength of sunscreen product do you use?

 

 

ANS:  C

Appropriate questions to ask an individual who is exposed to sunlight daily for many hours include options a, b, and d. Skin care habits to prevent ultraviolet exposure include using sunblock with appropriate sun protection factor (SPF) and wearing a hat, visor, long sleeves, or pants. The use of a hair dryer, heated curlers, or a curling iron can result in dry, brittle hair with broken ends. Asking about how often Ms. S cuts her hair is not a helpful question because it is not relevant to the health of her hair.

 

PTS:   1                    DIF:    Analysis

REF:   Nursing Checklist: Specific Health History Questions Regarding the Skin, Hair, and Nails

 

  1. Ms. B relates that she has received a weekly manicure and pedicure in various commercial salons within and outside of the United States for many years. You caution her that because standards of sterilizing equipment used in salons vary, she has an increased risk of:
a. hepatitis B.
b. Staphylococcus infection.
c. Candidiasis infection.
d. herpes simplex infection.

 

 

ANS:  A

Hepatitis B is transmitted by percutaneous exposure to infectious blood. The disease can be transmitted if the equipment used in a manicure or a pedicure comes in contact with the blood of a client who has hepatitis B and is used on another client without being sterilized. Equipment should be sterilized between clients. To eliminate this risk patients can bring their own equipment to be used during a manicure or pedicure. A Staphylococcus infection of the skin and subcutaneous tissues suggests cellulitis. Candidiasis is a yeast infection that normally occurs in the axillae, inframammary areas, groin, and gluteal regions. It causes patches that are beefy red in color, pruritic, and erythematous. Herpes simplex I virus causes lesions that are red papules, vesicles, open sores, and crusts, typically on the face and in the mouth.

 

PTS:   1                    DIF:    Application    REF:   Nursing Alert: Manicures and Pedicures

 

  1. When performing an assessment of skin, hair, and nails, you should enhance your visual inspection by using a magnifying glass and the best source of light, which is:
a. daylight.
b. fluorescent light.
c. incandescent light.
d. a flashlight.

 

 

ANS:  A

When assessing the skin, the nurse should control external variables that can influence skin color and confuse findings. The environment is one of these variables and includes light, room temperature, and cigarette smoking. Therefore, it is important to use a good source of natural light. If daylight is unavailable, overhead fluorescent lights should be added. An incandescent light emits a yellowish lightRemember, it is not the best option when assessing skin, hair, and nails. A flashlight does not emit adequate light to perform an assessment.

 

PTS:   1                    DIF:    Comprehension

REF:   Nursing Checklist: General Approach to Skin, Hair, and Nails Assessment

 

  1. When inspecting the skin, you should observe each area for the ten key characteristics, which are color, moisture, temperature, texture, turgor, edema,:
a. lesions, vascularity, bleeding, and ecchymosis.
b. pigmentation, bruising, bleeding, and eruptions.
c. xerosis, ecchymosis, distribution of hair, and vascularity.
d. vascularity, pigmentation, xerosis, and lesions.

 

 

ANS:  A

When inspecting the skin, the ten key characteristics to observe for are: 1) color,

2) bleeding, 3) ecchymosis, 4) vascularity, 5) lesions, 6) moisture, 7) temperature,

8) texture, 9) turgor, and 10) edema.  Thus, option a is correct. Option b is incorrect because pigmentation is included in assessing for coloration, and eruptions are a type of lesion. Option c is incorrect because xerosis (dry skin) is included in assessing for moisture and distribution of hair is a characteristic of hair assessment. Option d is incorrect because  pigmentation and xerosis are included under other characteristics.

 

PTS:   1                    DIF:    Comprehension                               REF:   Inspection of the Skin

 

  1. The presence of jaundice in a dark-skinned individual appears as a yellow to orange coloration of the:
a. skin, mucous membranes, and palmar and plantar surfaces.
b. fingernails and skin.
c. sclera, hard palate, and palmar and plantar surfaces.
d. sclera only.

 

 

ANS:  C

The appearance of jaundice is abnormal. Jaundice in a dark-skinned individual appears as yellow staining in the sclera, hard palate, and palmar or plantar surfaces. In light-skinned individuals jaundice appears as yellow-green to orange coloration of the skin, sclera, mucous membranes, fingernails, and palmar or plantar surfaces.

 

PTS:   1                    DIF:    Comprehension

REF:   Inspection of the Skin | Color

 

  1. Light-skinned patients with chronic renal disease often have a characteristic skin color associated with retained urochrome pigments and anemia described as:
a. bright red to ruddy appearance.
b. grayish cast to their skin.
c. orange-yellow coloration.
d. brown cast to their skin.

 

 

ANS:  B

A grayish cast to the skin is abnormal; is seen in renal patients; and is associated with chronic anemia. Uremia secondary to renal failure results in serum urochrome pigment retention. A bright red to ruddy appearance that is evident on the skin, mucous membranes, and palmar and plantar surfaces is abnormal in both light- and dark-skinned individuals. This ruddy appearance is the result of polycythemia or an increased number of red blood cells. An orange-yellow coloration is the result of jaundice. A brown cast to the skin occurs when there is a deposition of melanin that can be caused by genetic predisposition, pregnancy, Addison’s disease, cafe au lait spots, and sunlight.

 

PTS:   1                    DIF:    Comprehension

REF:   Inspection of the Skin | Color

 

  1. A white cast to the skin resulting from a congenital inability to form melanin is known as:
a. vitiligo.
b. pallor.
c. jaundice.
d. albinism.

 

 

ANS:  D

A white cast to the skin as evidenced by generalized whiteness, including the hair and eyebrows, is abnormal. This lack of coloration is caused by albinism, a congenital inability to form melanin. Vitiligo is a condition marked by patchy symmetrical areas of white on the skin. This condition is caused by an acquired loss of melanin. Trauma can also lead to hypopigmentation, especially in dark-skinned individuals. Jaundice produces a yellow-green to orange cast or coloration of the skin.

 

PTS:   1                    DIF:    Comprehension

REF:   Inspection of the Skin | Color

 

  1. Small, reddish purple discolorations of the skin, less than 0.5 cm in diameter, are known as:
a. ecchymoses.
b. petechiae.
c. purpura.
d. spider telangiectasia.

 

 

ANS:  B

Petechiae are violaceous (red-purple) discolorations of less than 0.5 cm in diameter. Petechiae do not blanch. They can indicate an increased bleeding tendency or embolism; causes include intravascular defects and infections. Ecchymosis is a violaceous discoloration of varying size, also called a black-and-blue mark. It is caused by extravasation of blood into the skin as a result of trauma; heparin or Coumadin use; or liver dysfunction. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis over any part of the body. Purpura is caused by hemorrhage into the skin and can be the result of decreased platelet formation. Spider angiomas, a type of telangiectasia, are bright red and star-shaped. Most often these lesions are found on the face, neck, and chest. There is often a central pulsation noted with pressure, and this results in blanching in the extensions.

 

PTS:   1                    DIF:    Comprehension

REF:   Bleeding, Ecchymosis, and Vascularity

 

  1. You are most likely to find petechiae during an assessment of a dark-skinned individual when inspecting the:
a. palmar surfaces.
b. mucous membranes and axillae.
c. sclera of the eyes.
d. tongue.

 

 

ANS:  B

In dark-skinned individuals petechiae are found in the mucous membranes and axillae. Jaundice in dark-skinned persons appears on the palmar and plantar surfaces and in the sclera. Petechiae are not typically located on the tongue of light- or dark-skinned individuals.

 

PTS:   1                    DIF:    Comprehension

REF:   Bleeding, Ecchymosis, and Vascularity

 

  1. Ecchymoses on the face, breasts, and buttocks of a 14-year-old girl are most likely to be related to:
a. liver dysfunction.
b. heparin or Coumadin use.
c. trauma from physical abuse.
d. familial blood condition.

 

 

ANS:  C

Ecchymosis is a bruise or superficial bleeding under the skin or mucous membranes. Areas of ecchymosis are often signs of trauma that could be the result of physical abuse. In a 14-year-old girl, such a finding on the face, breasts, and buttocks would most likely be caused by physical abuse. Ecchymosis can also occur with heparin or Coumadin use or liver dysfunction; however, these would not typically be located on the breasts and buttocks.

 

PTS:   1                    DIF:    Application    REF:   Nursing Alert: Signs of Abuse

 

  1. A bright red, star-shaped lesion on the face, neck, or chest that blanches with pressure is called a:
a. venous star.
b. cherry angioma.
c. hemangioma.
d. spider angioma.

 

 

ANS:  D

Spider angiomas are bright red and star-shaped. There is often a central pulsation noted with pressure, and this results in blanching in the extensions. Causes include pregnancy, liver disease, and hormone therapy. They are normal in a small percentage of the population and are more prevalent in women. Venous stars are linear, or irregularly shaped, blue vascular patterns that do not blanch with pressure. They are caused by increased venous pressure in the superficial veins. A cherry angioma is a bright-red circumscribed area, most often found on the trunk. The etiology is unknown; however, they are pathologically insignificant. A hemangioma is a congenital malformation of closely packed immature capillaries.

 

PTS:   1                    DIF:    Comprehension

REF:   Bleeding, Ecchymosis, and Vascularity

 

  1. The terms discrete, linear, annular, and zosteriform refer to which characteristic of skin lesions?
a. morphology
b. size
c. grouping or arrangement
d. types of exudate

 

 

ANS:  C

The grouping or arrangement of lesions is described as discrete, grouped, confluent, linear, annular, polycyclic, generalized, or zosteriform. Morphology refers to the form and structure of skin lesions. The terms primary and secondary refer to the morphology. The size of lesions is described in terms of centimeters. Use a ruler to measure. Exudate is defined as fluid, cells, or other substances that have been discharged from cells or blood vessels through small pores or breaks in the cell membranes. Types of exudate are perspiration, pus, and serum.

 

PTS:   1                    DIF:    Comprehension                               REF:   Lesions

 

  1. A nodule is an example of which type of lesion?
a. nonpalpable
b. palpable
c. secondary
d. tertiary

 

 

ANS:  B

Palpable lesions include papules, nodules, wheals, plaques, and tumors. Nodules are solid and elevated; however, they extend deeper than papules into the dermis or subcutaneous tissues, 0.5 to 2.0 cm. Examples of nodules are lipomas, erythema nodosum, cysts, melanomas, and hemangiomas. Nonpalpable lesions include macules and patches. Skin lesions can be primary or secondary. Primary lesions originate from previously normal skin. Secondary lesions originate from primary lesions.

 

PTS:   1                    DIF:    Comprehension

REF:   Figure 10-9 Morphology of Primary Lesions (E)

 

  1. Mr. D shows you an area on his right hand where a loss of epidermal tissue exposes the dermis. You recognize this lesion as a(n):
a. excoriation.
b. wheal.
c. keloid.
d. scar.

 

 

ANS:  A

Excoriation, an example of a secondary lesion, is described as the loss of epidermal layers exposing the dermis, such as an abrasion. A wheal is a primary lesion described as localized edema in the epidermis, causing an irregular elevation that can be red or pale, such as an insect bite, hives, and angioedema. A keloid is an enlargement of a scar past the wound edges resulting from excess collagen formation (more prevalent in dark-skinned individuals). It is a secondary lesion.

 

PTS:   1                    DIF:    Application

REF:   Figure 10-10 Morphology of Secondary Lesions (J)

 

  1. Ms. K expresses concern about a mole on her right leg that has recently started itching. Which accompanying finding most likely indicates a developing cancerous lesion?
a. regular and distinct border
b. multiple colorations
c. edema in both feet
d. inflammation of periungual tissue

 

 

ANS:  B

Developing cancerous lesions may have multiple colorations such as brownish, tan, red, white, blue, pink, purple, or gray. Other signs in potentially cancerous lesions include the following: 1) rapid change in size; 2) change in coloration; 3) irregular or butterfly-shaped border; 4) elevation in a previously flat mole; 5) multiple colorations in a lesion; 6) change in surface characteristics, such as oozing; 7) change in sensation, such as pain, itching, or tenderness; 8) change in surrounding skin, such as inflammation or induration; and

9) bleeding or ulcerative appearance in a mole. These lesions are not associated with edema or inflammation of the area around the fingernails or the toenails.

 

PTS:   1                    DIF:    Application

REF:   Nursing Alert: Danger Signs in Potentially Cancerous Lesions

 

  1. You note that Ms. L has diaphoresis, generalized hyperthermia, and very soft and silklike skin. In the absence of a fever or recent exercise, you determine that the most likely cause of these findings is:
a. hypothyroidism.
b. anxiety.
c. hyperthyroidism.
d. peripheral vascular disease.

 

 

ANS:  C

Hyperthyroidism is a condition characterized by hyperactivity of the thyroid gland. Metabolic processes of the body are accelerated.  Manifestations of this condition include diaphoresis, generalized hyperthermia, and very soft and silklike skin. Hypothyroidism is associated with findings such as dryness of  the skin.  Anxiety can cause diaphoresis or the profuse production of perspiration. Areas of hyperkeratosis and increased roughness of the skin on the lower extremities can be indicative of peripheral vascular disease.

 

PTS:   1                    DIF:    Analysis

REF:   Palpation of the Skin: Moisture, Temperature, and Texture

 

Mr. J, a 69-year-old patient in a nursing home, complains that his legs are cold all the time and his skin is dry and itchy. You note that Mr. J is wearing flannel nightclothes and has a wool blanket over his legs as he sits in a chair.

 

  1. Mr. J has areas of lichenification and excoriations on his arms and legs, which have most likely developed because of tissue damage from:
a. excessive scratching.
b. repeated skin infections.
c. poor nutrition and circulation.
d. scabies infestation.

 

 

ANS:  A

Localized thickening and roughness of the epidermis, known as lichenification, can be a result of chronic pruritus (lichenification) from excessive scratching. Excoriation, or loss of the epidermis, can also be caused by excessive scratching. Repeated skin infections can result in scars. Coolness of the arms and legs can be the result of poor nutrition and impaired circulation. Scabies is caused by the Sarcoptes scabiei mite which burrows into the stratum corneum depositing feces. This produces lesions that are red pruritic papules or vesicles with S-shaped or straight-lined burrows and are intensely pruritic.

 

PTS:   1                    DIF:    Application    REF:   Lesions

 

  1. The areas of Mr. J’s body that are optimal for assessing skin turgor are:
a. the upper arms and lower back.
b. the thighs and lower abdomen.
c. the anterior chest and abdomen.
d. over the clavicle and the lower arms.

 

 

ANS:  C

Skin turgor, or elasticity, is one of the estimates of adequate hydration and nutrition. Pinch a small section of the patient’s skin between the thumb and forefinger. The anterior chest, under the clavicle, and the abdomen are optimal areas to assess. Slowly release the skin. Observe the speed with which the skin returns to its original contour when released. It should return to its original contour rapidly. Options a, b, and d are incorrect because these areas of the body are not optimal to assess skin turgor.

 

PTS:   1                    DIF:    Application    REF:   Turgor

 

  1. After releasing the pressure of your thumb on Mr. J’s lower legs, ankles, and feet, you observe a 4 mm depression of the skin that disappears in 10 to 15 seconds. You would report:
a. 1+ pitting edema.
b. 2+ pitting edema.
c. 3+ pitting edema.
d. 4+ pitting edema.

 

 

ANS:  B

Edema is the accumulation of fluid in the intercellular spaces. Pitting edema is rated on a 4-point scale:

 

0+ = no pitting edema.

1+ = mild pitting edema; 2 mm depression that disappears rapidly.

2+ = moderate pitting edema. 4 mm depression that disappears in 10 to 15 seconds.

3+ = moderately severe pitting edema. 6 mm depression that can last more than 1 minute.

4+ = severe pitting edema. 8 mm depression that can last more than 2 minutes.

 

PTS:   1                    DIF:    Application    REF:   Edema

 

  1. Diascopy, an enhancement technique useful in assessing skin lesions, consists of:
a. using a magnifying glass to evaluate lesions and discolorations for morphology.
b. observing for blanching after pressing a microscope slide over the skin lesion.
c. noting color changes of the skin lesion under ultraviolet light.
d. using various stains to enhance microscopic examination of skin scrapings.

 

 

ANS:  B

Diascopy consists of pressing a microscopic slide over a skin lesion. It is useful in determining if a red lesion’s coloration is the result of erythema, which will blanch, or extravasation of blood, which will not blanch. Magnification consists of using a magnifying glass to evaluate lesions and discolorations for morphology. Wood’s lamp, also known as an ultraviolet light, is valuable in the diagnosis of certain skin and hair diseases. Dermatophytosis in the hair shaft appears green to yellow, and erythrasma will appear coral red.

 

PTS:   1                    DIF:    Comprehension

REF:   Nursing Tip: Enhancement Techniques

 

  1. Which individual should receive further assessment to determine the cause of the change in hair distribution?
a. Mr. B, 60 years old, has lost all of the hair on his scalp over the past 15 years.
b. Mrs. Y, 26 years old, has experienced an increase of facial hair in the past year.
c. Mr. K, 55 years old, has developed coarse dark hairs in his ears and nose.
d. Ms. W, 11 years old, has recently developed several dark hairs in her axillae and pubic area.

 

 

ANS:  B

Hirsutism is manifested by excessive facial and/or body hair. It is indicative of endocrine disorders such as hypersecretion of adrenocortical androgens and polycystic ovary syndrome. Therefore, the 26-year-old female who has experienced an increase of facial hair in the past year should most definitely receive further assessment to determine the cause. Total scalp baldness or alopecia can be caused by heredity, stress, emotional crisis, or autoimmune diseases. Thus, alopecia in a 60-year-old male may not be pathological. Increased coarse nose and ear hair occurs with aging in males. Hair developing in the axillae and pubic area is a normal occurrence of puberty.

 

PTS:   1                    DIF:    Analysis         REF:   Inspection of the Hair | Distribution

 

  1. When capillary refill is checked, the amount of time for the nail color to return after the pressure is released on the patient’s nail should not exceed:
a. 1–2 seconds.
b. 2–3 seconds.
c. 3–4 seconds.
d. 4–5 seconds.

 

 

ANS:  B

Capillary refill time is a measure used to assess arterial flow to the extremities and is an indicator of peripheral circulation. Normal capillary refill varies with age, but color should return to normal within 2–3 seconds. Options c and d indicate prolonged capillary refill time and may indicate cardiovascular or respiratory dysfunction. Option a would be considered within normal limits.

 

PTS:   1                    DIF:    Application    REF:   Inspection of the Nails | Color

 

  1. Clubbing occurs when:
a. purpura or ecchymosis develops under the nail plate.
b. the nail separates from the nail bed.
c. depression ridges develop horizontally down the middle of the nail.
d. the nail base is spongy and the angle is greater than 160°.

 

 

ANS:  D

Findings of clubbing occur when the angle of the nail base is greater than 160° and the nail bed is spongy. Clubbing occurs with chronic congenital cyanotic heart disease, emphysema, chronic bronchitis, and lung cancer. Purpura or ecchymosis under the nail plate is caused by a subungual hematoma from trauma to the digit and nail. Separation of the nail from the nail bed is called onycholysis and can result from hypothyroidism and hyperthyroidism, repeated trauma, Raynaud’s disease, syphilis, eczema, and acrocyanosis. Numerous horizontal depression ridges or a depression down the middle of the nail is caused by continuous picking of the cuticle and nail by a finger of the same hand. Trauma ensues to the nail base and nail matrix.

 

PTS:   1                    DIF:    Analysis         REF:   Shape and Configuration

 

  1. Central cyanosis is secondary to:
a. changes in outside temperature.
b. marked heart and lung disease.
c. nervous anxiety.
d. age-related changes in skin color.

 

 

ANS:  B

Central cyanosis is secondary to marked heart and lung diseases such as congestive heart failure, chronic obstructive pulmonary disease, or emphysema. Peripheral cyanosis can be secondary to systemic diseases or vasoconstriction stimulated by cold temperature or anxiety. Central cyanosis is not associated with age-related changes in skin color.

 

PTS:   1                    DIF:    Comprehension

REF:   Inspection of the Skin | Color

 

  1. A 5-year-old girl has had a rash on her arms and trunk for the past 48 hours and complains of pruritus. Three types of lesions are noted: macules, papules, and vesicles. Some of the vesicles have crusts. Based on your assessment, you conclude the girl has which disorder?
a. varicella
b. scabies
c. psoriasis
d. impetigo

 

 

ANS:  A

Varicella, or chickenpox, is characterized by red macular and papular lesions that are intensely pruritic. The lesions start on the trunk and proceed to the extremities. Papules progress to thin-walled vesicles, pustules, and crusts. It is caused by the varicella-zoster virus. The patient may exhibit all of the lesions simultaneously. Scabies is seen as red, pruritic papules or vesicles with S-shaped or straight-line burrows. It is caused by mites and may be visible as a small, dark area within the vesicle. Psoriasis has pruritic silvery scales of the epidermis that have clearly demarcated borders and underlying erythema. The lesions are circular and are found mainly on the elbows, knees, and behind the ears. The lesions of impetigo are vesicles or bullae that measure 1 to 2 cm and become pustular and rupture easily, discharging straw-colored fluid. The drainage becomes thick as it dries and produces golden-honey colored crusts. It is caused by group A streptococcus or Staphylococcus aureus.

 

PTS:   1                    DIF:    Analysis         REF:   Lesions

 

  1. Which of the following is a priority to include when instructing a patient to perform a skin assessment?
a. “Begin performing skin examinations after age 40.”
b. “Look for any changes in moles, especially color and size.”
c. “Evaluate the evenness of skin color, moisture, and temperature.”
d. “Assess the entire body and look for changes in skin or moles.”

 

 

ANS:  D

Skin self-assessment includes the entire body, looking for any changes in skin color as well as changes in moles. Performing a skin examination is an ongoing assessment and not just something that begins after age 40. Inspecting moles is an important part of a skin exam, but limits the skin assessment to moles only and negates the rest of the examination. Although evaluating the evenness of skin color, moisture, and temperature is an appropriate intervention, it is limited in its focus to two insignificant characteristics of skin: moisture and temperature. These do not change with the development of skin cancer.

 

PTS:   1                    DIF:    Application

REF:   Nursing Alert: Danger Signs in Potentially Cancerous Lesions

 

  1. The nurse is caring for a patient with a burn injury. Which of the following assessments would provide the nurse with the most accurate information about the type of burn?
a. red, dry, painful skin with no blisters
b. red, blistery, painful skin with serous exudate
c. leathery, dry, hard, painless skin
d. leathery, dry, hard, painless skin with exposed and damaged muscle and bone

 

 

ANS:  C

A burn that is red, dry, and painful without blisters describes a superficial thickness burn. An example is a sunburn. Serous exudate from a red, blistery wound that is painful describes a superficial, partial thickness burn. A burn that has leathery, dry, and hard skin that is painless describes a deep, partial thickness burn. Leathery, dry, hard, painless skin with exposed and damaged muscle and bone is a description of a full thickness burn.

 

PTS:   1                    DIF:    Application    REF:   Nursing Tip: Identifying Burns

 

  1. When assessing for changes in skin color in an African American patient, the nurse should assess which of the following first?
a. palms of the hands
b. nail beds or oral mucosa
c. soles of the feet
d. conjunctiva or sclera

 

 

ANS:  B

Assessment of the skin of those with naturally darker pigmentation should be done in an area where the epidermis is thin or in areas of least pigmentation, such as the nail beds or oral mucosa. The soles of the feet and palms of the hands are the second best options.

 

PTS:   1                    DIF:    Application    REF:   Inspection of the Skin | Color

 

COMPLETION

 

  1. Located in subcutaneous tissue, ____________________ cells trigger the body’s reaction to allergens.

 

ANS:

mast

Rationale: Mast cells are the body’s major source of tissue histamine and trigger the body’s reaction to allergens. These cells are distributed around the dermal blood vessels and the subcutaneous tissue and number from 7,000 to 20,000 per cubic centimeter of skin.

 

PTS:   1                    DIF:    Knowledge    REF:   Subcutaneous Tissue

 

  1. The fine hair that covers the majority of the body is called ____________________ hair.

 

ANS:

vellus

Rationale: Hair is distributed over the entire body surface with few exceptions (the palmar and plantar surfaces, lips, nipples, and the glans penis). Vellus hair, or fine, faint hair, covers most of the body. Terminal hair is the coarser, darker hair of the scalp, eyebrows, eyelashes, and in the axillary and pubic areas of both males and females. Males also tend to develop coarser, thicker chest and facial hair.

 

PTS:   1                    DIF:    Knowledge    REF:   Hair

 

  1. A white cast to the skin resulting from a congenital inability to form melanin is known as ____________________.

 

ANS:

albinism

Rationale: A white cast to the skin as evidenced by generalized whiteness, including the hair and eyebrows, results from a lack of coloration caused by albinism. Albinism is a congenital inability to form melanin.

 

PTS:   1                    DIF:    Knowledge    REF:   Color

 

  1. A stage ____________________ pressure ulcer will show damage to the subcutaneous tissues.

 

ANS:

3

three

Rationale: Uniform standards for staging pressure ulcers are used for patients with pressure sores on any portion of the body. Stage 1: In light-skinned patients, the area is reddened, but the skin is not broken; in dark-skinned patients, the pigmentation is enhanced. Stage 2: The epidermal and dermal layers have sustained injury. Stage 3: The subcutaneous tissues have sustained injury. Stage 4: Muscle tissue and perhaps bone have sustained injury.

 

PTS:   1                    DIF:    Comprehension

REF:   Nursing Alert: Stages of Pressure Ulcers

 

  1. The largest organ of the body is the skin, also known as the ____________________ system, or cutaneous tissue.

 

ANS:

integumentary

Rationale: The skin, also known as the integumentary system, or cutaneous tissue, is the largest organ system of the body. It shelters most of the other organ systems, and if assessed carefully, it can provide a noninvasive window to observe the body’s level of functioning.

 

PTS:   1                    DIF:    Knowledge    REF:   Introduction

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