Nokea
A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
- A. Vesicle
- B. Macule
- C. Nodule
- D. Wheal
Correct Answer: D
Rationale: A wheal is an elevated lesion with serous fluid in the dermis, such as a mosquito bite. Vesicles contain fluid but are circumscribed, macules are flat, and nodules are solid.
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A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?
- A. Skin scrapings
- B. Skin biopsy
- C. Patch testing
- D. Tzanck smear
Correct Answer: C
Rationale: Patch testing identifies allergens causing contact dermatitis. Skin scrapings are for fungal infections, biopsies rule out malignancy, and Tzanck smears diagnose blistering conditions.
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 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 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.