Nokea
A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient?
- A. Ulcer
- B. Ecchymosis
- C. Scar
- D. Erosion
Correct Answer: B
Rationale: Ecchymosis, or bruising, is a risk with anticoagulants like warfarin due to blood extravasation. Ulcers, scars, and erosions are not directly associated with anticoagulant use.
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A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation?
- A. Alopecia
- B. Yellowish skin tone
- C. Patchy, bronze pigmentation
- D. Hirsutism
Correct Answer: D
Rationale: Cushing syndrome causes hirsutism, especially in women, due to excess cortisol. Alopecia, yellowish skin, and bronze pigmentation are not typical features.
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
- A. Does anyone in your family have eczema or psoriasis?
- B. Have any of your family members been diagnosed with malignant melanoma?
- C. Do you have a family history of vitiligo or port-wine stains?
- D. Does any member of your family have a history of keloid scarring?
Correct Answer: A
Rationale: Eczema and psoriasis have a known genetic component, making this the most relevant question. Melanoma, vitiligo, port-wine stains, and keloid scarring have less consistent genetic links.
An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many spots on her skin. What would be an appropriate response by the nurse?
- A. As people age, they normally develop uneven pigmentation in their skin.
- B. These spots are called liver spots or age spots.
- C. Older skin is more apt to break down and tear, causing sores.
- D. These are usually the result of nutritional deficits earlier in life.
Correct Answer: A
Rationale: Uneven pigmentation, such as age spots, is a common age-related skin change. Naming the spots or discussing skin breakdown does not directly address the cause, and nutritional deficits are not typically responsible.
A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?
- A. Tzanck smear
- B. Skin biopsy
- C. Patch testing
- D. Skin scrapings
Correct Answer: B
Rationale: A skin biopsy is used to diagnose or rule out skin malignancies like melanoma. Tzanck smears diagnose blistering conditions, patch testing identifies allergens, and skin scrapings detect fungal infections.
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
- A. Elbows
- B. Lips
- C. Nail beds
- D. Sclerae
Correct Answer: D
Rationale: Jaundice, caused by elevated serum bilirubin, is best observed in the sclerae and mucous membranes, especially in darker-skinned individuals where skin pigmentation may mask changes.