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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.
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A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?
- A. Has she eaten any new foods today?
- B. Has she bathed in the past 24 hours?
- C. Did she go to a friends house today?
- D. Was she digging in the dirt today?
Correct Answer: A
Rationale: Food allergies are a common cause of urticaria in children. Bathing, visiting friends, or soil exposure are less likely to be relevant triggers.
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.
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.
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
- A. Macules
- B. Papules
- C. Vesicles
- D. Pustules
Correct Answer: A
Rationale: Macules are flat, nonpalpable skin color changes. Papules are elevated and solid, vesicles contain serous fluid, and pustules are pus-filled.
A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply.
- A. Producing antibodies
- B. Absorbing electrolytes
- C. Maintaining acidbase balance
- D. Physically repelling pathogens
- E. Preventing fluid loss
Correct Answer: D,E
Rationale: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acidbase balance, or electrolyte levels.