Nokea
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.
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A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?
- A. Is the rash worse at a particular time or season?
- B. Are you allergic to any foods or medication?
- C. Are you having any loss of sensation in that area?
- D. Is your rash painful?
Correct Answer: B
Rationale: A new rash during antibiotic therapy suggests a possible allergic reaction, which could be life-threatening. Assessing for allergies is the priority over timing, sensation, or pain.
An older adult patient is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse?
- A. Spend time outdoors at least twice per week
- B. Increase intake of leafy green vegetables
- C. Start taking a multivitamin each morning
- D. Eat red meat at least once per week
Correct Answer: A
Rationale: Sun exposure twice weekly promotes vitamin D synthesis in the skin. Leafy greens, multivitamins, and red meat may not adequately address a specific vitamin D deficiency.
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.
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.
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.