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The nurse is caring for a patient who has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. Which of the following actions would the nurse implement to determine whether the lesion is related to blood vessel dilation?
- A. Elevate the patient's leg
- B. Press firmly on the lesion.
- C. Check the temperature of the skin around the lesion.
- D. Palpate the dorsalis pedis and posterior tibial pulses.
Correct Answer: B
Rationale: If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.
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Which assessment information documented in a patient's chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old patient admitted with bacterial pneumonia?
- A. Scattered macular brown areas on extremities
- B. Skin brown and wrinkled, skin tenting on forearm
- C. Longitudinal nail bed ridges noted, sparse scalp hair
- D. Skin moist and intact, states history of allergic rashes
Correct Answer: D
Rationale: Because the patient will be receiving antibiotics, the nurse should monitor the patient for the presence of an allergic rash. The assessment data in the other responses would be normal for an elderly patient.
The nurse is caring for a patient who reports persistent itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for which of the following conditions?
- A. Skin atrophy
- B. Lichenification
- C. Skin varicosity
- D. Keloid formation
Correct Answer: B
Rationale: Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, or varicosities.
The nurse is conducting a health history with a patient and the nurse discovers that the patient works as a roofer. The nurse will plan to teach the patient about how to self-assess for clinical manifestations of which of the following integument conditions?
- A. Alopecia
- B. Intertrigo
- C. Wrinkling
- D. Erythema
- E. Actinic keratosis
Correct Answer: C,D,E
Rationale: A patient who works as a roofer is at risk for integumentary lesions caused by sun exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are not associated with excessive sun exposure.
A patient asks the nurse why a potassium hydroxide test needs to be done. The nurse's response is based upon the knowledge that which of the following is the purpose of this test?
- A. Examine a lesion via a biopsy.
- B. Obtain fluids from vesicles for assessment.
- C. Assess for fungal infection.
- D. Scrap exudate from a lesion for microscopic examination.
Correct Answer: C
Rationale: A potassium hydroxide test is done to examine hair, nails, or scales for superficial fungal infection. Scraping exudate from a lesion for examination is used with mineral oil slides. A Tzanck test is used when fluid is obtained from vesicles for assessment.
The nurse is caring for a patient in the dermatology clinic who is scheduled for removal of a 15-mm multicoloured and irregular mole from the upper back. Which of the following biopsies would the nurse teach to this patient?
- A. Shave
- B. Punch
- C. Incisional
- D. Excisional
Correct Answer: C
Rationale: An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant: a shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.