WorksheetsIntegumentary
Total questions: 50
Worksheet time: 2hrs 36mins
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
Stage I
Stage II
Stage III
Stage IV
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are mostimportant for the nurse to teach the mother?
Change the patient’s bedding frequently.
Use a hydrocolloid dressing over the ulcer.
Record the size and appearance of the ulcer weekly.
Change the patient’s position at least every 2 hours.
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes insulin daily.
The patient states that the ulcers are very painful.
The patient has had the heel ulcers for the last 6 months.
The patient has several old incisions that have formed keloids.
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?
Assess the skin color of the earlobes.
Apply pressure to the palms of the hands.
Check the lips and oral mucous membranes.
Examine capillary refill time of the nail beds.
When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next?
Assess the patient for evidence of liver disease.
Discuss the adverse effects of sun exposure on the skin.
Teach the patient about possible skin changes with aging.
Suggest that the patient make an appointment with a dermatologist.
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
Use a sunscreen with an SPF of at least 8 to 10 for adequate protection.
Water resistant sunscreens will provide good protection when swimming.
Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).
A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan?
Treatment plans include watchful waiting.
Screening for metastasis will be important.
Low dose systemic chemotherapy is used to treat BCC.
Minimizing sun exposure will reduce risk for future BCC.
The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?
Clean the infected areas with soap and water.
Apply alcohol-based cleansers on the lesions.
Avoid use of antibiotic ointments on the lesions.
Use petroleum jelly (Vaseline) to soften crusty areas.
A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
Ringlike rashes with red, scaly borders over the entire scalp
Papular, wheal-like lesions with white deposits on the hair shaft
Patchy areas of alopecia with small vesicles and excoriated areas
Red, hivelike papules and plaques with sharply circumscribed borders
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?
Thinning of the affected skin
Alopecia of the affected areas
Reddish-brown discoloration of the skin
Dryness and scaling in the areas of treatment
Which information will the nurse include when teaching an older patient about skin care?
Dry the skin thoroughly before applying lotions.
Bathe and wash hair daily with soap and shampoo.
Use warm water and a moisturizing soap when bathing.
Use antibacterial soaps when bathing to avoid infection.
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)?
Cool, wet cloths or dressings can be used to reduce itching.
Take cool or tepid baths several times daily to decrease itching.
Add oil to your bath water to aid in moisturizing the affected skin.
Rub yourself dry with a towel after bathing to prevent skin maceration.
Use of an over-the-counter (OTC) antihistamine can reduce scratching.
A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?
Assess frequently for herpes zoster
Be aware of the patient’s immunity to chickenpox
Encourage the patient to have a pneumonia vaccine
Arrange for the patient to receive gamma globulin
A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are:
chickenpox.
impetigo.
shingles.
herpes simplex type I.
A patient, age 46, reports to his physician’s office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, “It itches like crazy.” Which type of lesion would the nurse include in her documentation?
Macules
Plaques
Wheals
Vesicles
What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne?
Avoid alcoholic beverages
Drink at least 1000 mL of fluid daily
Use dependable birth control to avoid pregnancy
Avoid exposure to the sun
A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
Angioma
Keloid
Melanoma
Nevus
A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
Within 12 hours after burn trauma
24 to 36 hours after burn trauma
24 to 48 hours after burn trauma
48 to 72 hours after burn trauma
Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
Curling ulcer
Paralytic ileus
Hypoglycemia perforation of the stomach by the NG tube
Gastritis
The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a:
stage I
stage II
stage III
stage IV
What should the nurse examine in assessing a patient for tinea corporis?
Soles of the feet
Scalp
Armpits
Abdomen
The nurse debriding a burn wound explains that the purpose of debridement is to:
increase the effectiveness of the skin graft.
prevent infection and promote healing.
promote suppuration of the wound.
promote movement in the affected area.
A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
Decreased activity
Bradycardia
Respiratory complications
Hypertension
Which may indicate a malignant melanoma in a nevus on a patient’s arm?
Even coloring of the mole
Decrease in size of the mole
Irregular border of the mole
Symmetry of the mole
The school nurse recognizes the signs of scabies when a child presents with:
small fluid filled blisters that sting when scratched.
dry scaly patches in body creases that itch.
wavy threadlike lines on the body and pruritus.
cluster of papular lesions with pruritus.
Which of the following are nursing interventions and patient teaching for the treatment of head lice and scabies? (Select all that apply.)
Clothing, linens, and bath articles thoroughly cleaned in hot water
Stress nature and transmission of the disease
Special carbohydrate diet to promote healing
Complete isolation from the public
The nurse is aware that the gradual graying of an older adult’s hair is related to:
reduced hair follicles.
less sebaceous gland activity.
loss of collagen fibers in dermis.
decreased melanocytes at hair follicle.
An 80-year-old resident prefers to lie in bed on her left side. The nurse will take extra care in assessing the left ______ for evidence of skin breakdown.
buttock
heel
trochanter
ribs
A 93-year-old resident eats only a few bites at meals and then refuses to eat more. To help delay skin breakdown from diminished nutrition, the nurse would:
spoon-feed the resident.
request an order for a feeding tube.
inform resident of the need to increase intake.
offer 4 ounces of fluid every hour.
The nurse teaches the patient the “ABCD” technique for evaluating melanomas. In this memory prompt, the “D” stands for:
darkness.
drainage.
dimpling.
diameter.
The nurse advises the older adult to alter bathing practices to include: (Select all that apply.)
using lotion-based soaps.
using hot water to stimulate skin.
strenuous toweling to dry skin.
applying lotion twice a day.
using talcum to dry out skin.
The nurse advises a 20-year-old college sophomore with acne vulgaris to:
avoid all chocolate.
wash the face gently with mild soap.
scrub the face with soft brush.
express clogged sebum from the pores.
The nurse recommends that the person who suffers with psoriasis can increase his comfort by:
using drying solutions such as alcohol to clean psoriasis plaques.
using a humidifier to keep psoriasis plaques moist.
applying wet dressing to minimize proliferation.
taking hot baths to reduce skin discomfort.
An 84-year-old patient who has had a low-grade fever for 2 days complains of pain in the hip that travels down the leg along the sciatic nerve. The nurse assesses small groups of vesicles along the nerve path. These assessments lead the nurse to suspect that the patient is suffering from:
herpes simplex.
shingles.
carbuncles.
furuncles.
The home health nurse instructs the family whose child came home from school with lice that the bed linens should be:
thrown out in a sealed garbage bag.
washed with strong bleach solution.
washed and dried on the hottest setting.
washed and dried at least through three cycles.
The nurse explains that the primary purpose of the whirlpool bath given to the patient with a stage III pressure ulcer is to:
keep the patient clean.
stimulate granulation tissue growth.
improve circulation in surrounding skin.
provide moisture to the ulcer.
To prevent contractures in the burn patient, the nurse should:
assist the patient to ambulate as soon as fluid shift has stabilized.
leave the limbs in full extension.
stop range-of-motion (ROM) exercises when the patient complains of pain.
place the limbs in the flexion position.
The nurse read in the patient’s chart that the patient has a stage III pressure ulcer. Which assessment findings are consistent with this stage of ulcer?
Damage to the subcutaneous tissue
Unblanching skin
Presence of mottled skin
Damage limited to the epidermis
The interventions for a burn patient newly admitted to the emergency department include: (Select all that apply.)
covering the burn with sterile saline–saturated towel.
removing clothing stuck to burn.
taking care not to disturb blisters.
removing jewelry from injured limbs.
assessing the cause of the burn.
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?
The patient has multiple dysplastic nevi.
The patient is fair-skinned and has blue eyes.
The patient’s mother died of a malignant melanoma.
The patient uses a tanning booth throughout the winter.
Pressure ulcers are directly caused by which of the following conditions at the site?
Compromised blood flow
Edema
Shearing forces
Inadequate venous return
The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:
The ulcer is completely healed with minimal scarring.
The patient reports no pain at the site.
A minimal amount of drainage is noted.
The wound bed contains 100% granulated tissue.
Which client does the nurse recognize as being at greatest risk for pressure ulcers?
Infant with skin excoriations in the diaper region
Young adult with diabetes in skeletal traction
Middle-aged adult with quadriplegia
Older adult requiring use of assistive device for ambulation
The nurse notices small purplish dots on the abdomen of a patient. Which statement should the nurse use to document the finding?
“Diffuse erythema of the abdomen.”
“Purpura scattered across abdomen.”
“Scattered ecchymoses noted on abdomen.”
“Multiple petechiae noted across the abdomen.”
The nurse notes small (less than 0.5 cm), raised areas that contain serous fluid on a patient’s arm. What term should the nurse use to document this finding?
Cyst
Papule
Macule
Vesicle
The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding should cause the nurse the most concern?
Edema formation
Dry, macerated skin
Increased lesion oozing
Excessive skin oiliness
The nurse is noting the texture of a patient’s skin and hair. Which secretion should the nurse identify that prevents drying of skin and hair?
Sweat
Sebum
Melanin
Cerumen
A patient has a pressure ulcer that has purulent drainage, areas if black material, foul smelling, and painful. What should the nurse do first for healing to occur?
Wound culture
Wound débridement
Topical antibiotic administration
Intravenous antibiotic administration
The nurse is assessing a patient with pemphigus. What skin manifestations should the nurse expect to observe?
Rash
Bullae
Wheals
Vesicles
The nurse is caring for an immobile patient being treated for diabetes mellitus and a urinary tract infection. What should be included in a plan of care to prevent pressure ulcers in this patient? (Select all that apply.)
Apply moisturizer to the skin after bathing.
Reposition the patient at least every 2 hours.
Elevate the head of the bed no more than 30 degrees.
Massage bony prominences including hips and elbows.
Place the patient on a donut-shaped cushion when sitting.
