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A nurse is providing an educational presentation addressing the topic of Protecting Your Skin. When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin?
- A. Islets of Langerhans
- B. Squamous cells
- C. T cells
- D. Melanocytes
Correct Answer: D
Rationale: Melanocytes produce melanin, the pigment responsible for skin color. Islets of Langerhans are pancreatic cells, squamous cells are epithelial, and T cells are immune cells.
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A patient with human immunodeficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what?
- A. A reduction in the patients CD4 count
- B. A reduction in the patients viral load
- C. An adverse effect of antiretroviral therapy
- D. Virus-induced changes in allergy status
Correct Answer: A
Rationale: Skin lesions in HIV often indicate a declining CD4 count, reflecting immune deterioration. Viral load typically increases, not decreases, and antiretrovirals or allergy changes are less likely causes.
A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?
- A. Weak positive
- B. Moderately positive
- C. Strong positive
- D. Severely positive
Correct Answer: B
Rationale: Fine blisters, papules, and severe itching indicate a moderately positive patch test reaction. Weak positive shows redness and itching, while strong positive includes blisters and ulceration.
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.
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
- A. Decreased resistance to ultraviolet radiation
- B. Increased vulnerability to infection
- C. Diminished protection of tissues and organs
- D. Increased risk of skin malignancies
Correct Answer: C
Rationale: Loss of subcutaneous tissue reduces cushioning and insulation for underlying tissues and organs. It does not directly affect UV resistance, infection risk, or malignancy risk.
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
- A. By avoiding the use of moisturizing lotions on older adults skin
- B. By protecting older adults against shearing injuries
- C. By avoiding the use of ice packs to treat muscle pain
- D. By protecting older adults against excessive sweat accumulation
Correct Answer: B
Rationale: Aging causes thinning at the dermis-epidermis junction, increasing the risk of shearing injuries. Moisturizers are beneficial for dry skin, ice packs can be used with caution, and sweat accumulation is not a concern in older adults.