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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.
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A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?
- A. Dermis
- B. Subcutaneous tissue
- C. Epidermis
- D. Stratum corneum
Correct Answer: B
Rationale: The subcutaneous tissue (hypodermis) cushions between skin layers, muscles, and bones. The dermis provides strength, the epidermis is the outer layer, and the stratum corneum is the outermost epidermal layer.
The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?
- A. An insect bite
- B. Dehydration
- C. Sunburn
- D. Excessive perspiration
Correct Answer: A
Rationale: An insect bite represents penetration of the skin by an environmental factor, breaching the stratum corneum. Dehydration, sunburn, and perspiration are not examples of penetration.
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.
An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patients course of treatment?
- A. Increased thickness of the subcutaneous skin layer
- B. Increased vascular supply to superficial skin layers
- C. Changes in the character and quantity of bacterial skin flora
- D. Increased time required for wound healing
Correct Answer: D
Rationale: Aging slows wound healing, complicating treatment of pressure ulcers. Subcutaneous tissue and vascular supply decrease with age, and skin flora does not significantly change.
A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?
- A. Obtain a swab for culture.
- B. Assess the characteristics of the lesion.
- C. Obtain a swab for pH testing.
- D. Apply a test dose of broad-spectrum topical antibiotic.
Correct Answer: B
Rationale: Assessing and documenting the characteristics of an open lesion is the priority to guide further diagnostics or treatment. Culture, pH testing, or antibiotics should follow assessment.