Nokea
A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
- A. Telangiectasias
- B. Ecchymoses
- C. Purpura
- D. Urticaria
Correct Answer: B
Rationale: Ecchymoses are bruises, characterized by larger areas of blood extravasation under the skin. Telangiectasias are dilated superficial blood vessels, purpura are pinpoint hemorrhages, and urticaria are wheals or hives.
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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.
Assessment of a patients leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
- A. Keloid
- B. Ulcer
- C. Fissure
- D. Erosion
Correct Answer: B
Rationale: An ulcer involves skin loss past the epidermis with necrotic tissue. Keloids are scar tissue, fissures are linear, and erosions are superficial.
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.
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.
A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patients fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?
- A. Eczema
- B. Systemic lupus erythematosus (SLE)
- C. Psoriasis
- D. Chronic obstructive pulmonary disease (COPD)
Correct Answer: C
Rationale: Pitted nails are a hallmark of psoriasis. Eczema, SLE, and COPD do not typically cause nail pitting.