Nokea
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?
- A. Sebum deficiency
- B. Fluid retention
- C. Dehydration
- D. Protein deficiency
Correct Answer: B
Rationale: Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.
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An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned about the possibility of having melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?
- A. Senile keratoses
- B. Senile lentigines
- C. Melanoma
- D. Freckles
Correct Answer: B
Rationale: Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.
A client has a wart on the left knee but wants to try an over-the-counter medication to dissolve the wart. What type of solution would the nurse educate the client about?
- A. Antiseborrheic agents
- B. Antihistamine
- C. Antiseptics
- D. Keratolytics
Correct Answer: D
Rationale: Keratolytics dissolve thickened, cornified skin such as warts, corns, and calluses. Their action causes the treated area to soften and swell, facilitating removal. Antiseborrheic agents are applied to the scalp or incorporated into shampooing products to control dandruff. Antihistamines are used to relieve itching. An antiseptic would be used to reduce bacteria on the arm.
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
- A. Concave
- B. Brittle
- C. Discolored
- D. Clubbing
Correct Answer: D
Rationale: Clubbing of the nails is evidenced by an angle greater than 160?° and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or 'spooning' may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.
Which of the following causes odor in perspiration?
- A. Sunlight
- B. Bacteria on the skin
- C. Air pollutants
- D. Cloudy environment
Correct Answer: B
Rationale: Perspiration is odorless. An odor develops when perspiration mixes with bacteria on the skin. Sunlight, air pollutants, and a cloudy environment do not cause odor in perspiration.
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.