Nokea
The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?
- A. Cherry angiomas
- B. Solar lentigo
- C. Seborrheickeratoses
- D. Xanthelasma
Correct Answer: A
Rationale: Cherry angiomas are benign, bright red moles common in older adults. Solar lentigo are liver spots, seborrheickeratoses are crusty brown patches, and xanthelasma are yellowish deposits on the eyelids.
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A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
- A. Does anyone in your family have eczema or psoriasis?
- B. Have any of your family members been diagnosed with malignant melanoma?
- C. Do you have a family history of vitiligo or port-wine stains?
- D. Does any member of your family have a history of keloid scarring?
Correct Answer: A
Rationale: Eczema and psoriasis have a known genetic component, making this the most relevant question. Melanoma, vitiligo, port-wine stains, and keloid scarring have less consistent genetic links.
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 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.
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.
The nurse is performing a comprehensive assessment of a patients skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
- A. By examining the patient under a Woods light
- B. By inspecting the patients skin in direct sunlight
- C. By palpating the patients skin
- D. By performing percussion of major skin surfaces
Correct Answer: C
Rationale: Palpation assesses skin moisture, temperature, and texture. Woods light is for pigmentation, sunlight is impractical, and percussion is not used for skin assessment.