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An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patients face is a cherry-red color. What should the nurse suspect?
- A. Carbon monoxide poisoning
- B. Anemia
- C. Jaundice
- D. Uremia
Correct Answer: A
Rationale: Carbon monoxide poisoning causes a cherry-red color in light-skinned patients' face and upper torso. Anemia causes pallor, jaundice causes yellowing, and uremia causes a yellow-orange tinge.
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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.
When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
- A. The scalp
- B. The elbows
- C. The palms of the hands
- D. The knees
Correct Answer: C
Rationale: The epidermis is the thickest over the palms of the hands and the soles of the feet, providing greater protection in these high-contact areas.
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 gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
- A. By avoiding the use of moisturizing lotions on older adults skin
- B. By protecting older adults against shearing injuries
- C. By avoiding the use of ice packs to treat muscle pain
- D. By protecting older adults against excessive sweat accumulation
Correct Answer: B
Rationale: Aging causes thinning at the dermis-epidermis junction, increasing the risk of shearing injuries. Moisturizers are beneficial for dry skin, ice packs can be used with caution, and sweat accumulation is not a concern in older adults.
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.