NSG 3160 Exam 2 Review

Front

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

Back

An increased loss of elastin and a decrease in subcutaneous fat

Answer explanation

An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. With aging there is a decrease in the vascularity, number of sweat and sebaceous glands, and elastin not an increase.

Front

A 22-year-old woman comes to the clinic because of severe sunburn and states, “I was out in the sun for just a couple of minutes.” The nurse begins a medication review with her, paying special attention to which medication class?

Back

Tetracyclines for acne

Answer explanation

Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline. Proton pump inhibitors, nonsteroidal anti-inflammatories, and thyroid replacement hormone are not associated with skin sensitivities or sunburn.

Front

What would the nurse include in the teaching of vitiligo?

Back

It is caused by the complete absence of melanin pigment in an area.

Answer explanation

Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

Front

A 42-year-old woman has noticed several small, slightly raised, bright red dots on her chest. How would the nurse document these findings?

Back

Senile angiomas

Answer explanation

Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old. Anasarca is bilateral or generalized edema all over the body. Scleroderma is tight, “hard” skin that causes problems with mobility. Myeloma is cancer of plasma cells. The small, smooth, slightly raised bright red dots this patient has are cherry (senile) angiomas. These commonly appear on the trunk of adults over 30 years old.

Front

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and “stuck on” his skin. Which is the best description of these?

Back

Seborrheic keratoses, which do not become cancerous

Answer explanation

Seborrheic keratoses appear like dark, greasy, “stuck-on” lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Acrochordons are skin tags and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly r/t sun exposure. They are premalignant and may develop into squamous cell carcinoma.

Front

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How would the nurse document this finding?

Back

A papule

Answer explanation

A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm. The solid, elevated, circumscribed lesion less than 1 cm in diameter that this patient has is a papule.

Front

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. What is the best response by the nurse? Options: “Blue dilation of blood vessels in a star-shaped linear pattern on the legs”, “Fiery red, star-shaped marking on the cheek that has a solid circular center”, “Confluent and extensive patch of petechiae and ecchymoses on the feet”, “Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color”

Back

Confluent and extensive patch of petechiae and ecchymoses on the feet.

Answer explanation

Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describe petechiae.

Front

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect?

Back

Damage to the trigeminal nerve

Answer explanation

Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

Front

A patient comes to the clinic reporting neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how would the nurse proceed with the examination?

Back

XI; have patient shrug their shoulders against resistance.

Answer explanation

The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To assess the function of cranial nerve XI the nurse should have the patient shrug their shoulders against resistance. Cranial nerve XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech and swallowing it does not affect balance which is what the Romberg sign assesses. Identifying the anterior and posterior triangles are helpful guidelines when describing findings in the neck but palpating them does not assess any cranial nerves. Cranial nerve XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech and swallowing and percussion of the sternomastoid and submandibular neck muscles does not assess CN XII.

Front

The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas would the nurse include in the explanation to the student?

Back

Head and neck, arms, inguinal area, and axillae

Answer explanation

Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae. Lymph nodes in the breasts, abdomen, and legs are not accessible.