Nokea
A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves? Select all that apply.
- A. Palpation of the patients scalp
- B. Palpation of the patients upper extremities
- C. Palpation of a rash on the patients trunk
- D. Palpation of a lesion on the patients upper back
- E. Palpation of the patients fingers
Correct Answer: C,D
Rationale: Gloves are required when palpating rashes or lesions to prevent contact with potential infectious material. Palpation of scalp, extremities, or fingers does not typically require gloves unless body fluids are present.
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A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?
- A. Crust
- B. Keloid
- C. Pustule
- D. Ulcer
Correct Answer: C
Rationale: A pustule is a primary skin lesion, arising from previously normal skin. Crusts, keloids, and ulcers are secondary lesions resulting from changes to primary lesions.
A dermatologist has asked the nurse to assist with examination of a patients skin using a Woods light. This test will allow the physician to assess for which of the following?
- A. The presence of minute regions of keloid scarring
- B. Unusual patterns of pigmentation on the patients skin
- C. Vascular lesions that are not visible to the naked eye
- D. The presence of parasites on the epidermis
Correct Answer: B
Rationale: Woods light helps identify pigmentation patterns, distinguishing epidermal from dermal lesions. It does not detect keloids, vascular lesions, or parasites.
A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?
- A. E
- B. D
- C. A
- D. C
Correct Answer: B
Rationale: Ultraviolet light exposure aids in synthesizing vitamin D, essential for preventing rickets and supporting bone health. Vitamins E, A, and C are not synthesized via sunlight.
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
- A. Is anyone in your family allergic to anything?
- B. How long have you had this abrasion?
- C. Do you take any over-the-counter drugs or herbal preparations?
- D. What do you do for a living?
Correct Answer: C
Rationale: Asking about over-the-counter drugs or herbal preparations can identify potential causes of a rash. Family allergy history, occupation, or mislabeling the rash as an abrasion are less immediately relevant.
The nurse is performing a comprehensive assessment of a patients skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
- A. By examining the patient under a Woods light
- B. By inspecting the patients skin in direct sunlight
- C. By palpating the patients skin
- D. By performing percussion of major skin surfaces
Correct Answer: C
Rationale: Palpation assesses skin moisture, temperature, and texture. Woods light is for pigmentation, sunlight is impractical, and percussion is not used for skin assessment.