Nokea
The nurse is caring for a patient who has several angiomas on their legs. Which of the following actions should the nurse take next?
- A. Assess the patient for evidence of liver disease.
- B. Discuss the adverse effects of sun exposure on the skin.
- C. Educate the patient about possible skin changes with aging.
- D. Suggest that the patient make an appointment with a dermatologist.
Correct Answer: A
Rationale: Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment.
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The nurse is conducting a health assessment on an older-adult patient and is assessor the patient's nails. Which of the following assessments are age-related changes?
- A. Longitudinal ridging
- B. Decreased keratin
- C. Decreased circulation
- D. Thick, brittle nails
- E. Increased peripheral blood supply
Correct Answer: A,C,D
Rationale: Age-related changes to the nails include a decreased peripheral blood supply and circulation, increased keratin, thick, brittle nails, longitudinal ridging, and a prolonged return of blood to nails on blanching. Decreased keratin and increased peripheral blood supply are not typical age-related changes.
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 who is dark-skinned and has been admitted to the hospital in severe respiratory distress. Which of the following actions should the nurse implement to determine whether the patient is cyanotic?
- A. Assess the skin colour of the earlobes
- B. Apply pressure to the palms of the hands.
- C. Check the lips and oral mucous membranes.
- D. Examine capillary refill time of the nail beds.
Correct Answer: C
Rationale: Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe colour may change in light-skinned individuals, but this change in skin colour is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation, but not for skin colour.
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.
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.