Nokea
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.
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The nurse is conducting an assessment of the patient's skin and observes a ring of small, raised, discrete lesions filled with serous fluid on the patient's right temple. Which of the following descriptions would the nurse use when documenting the lesions?
- A. Grouped
- B. Confluent
- C. Zosteriform
- D. Generalized
Correct Answer: A
Rationale: The description of the lesions indicates that they are grouped. Confluent lesions merge into one another, zosteriform lesions follow a dermatome, and generalized lesions are widespread across the body.
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.
The nurse is admitting an older-adult patient to an assisted-living facility and notes abnormalities on the skin. Which of the following abnormalities is the priority to discuss immediately with the health care provider?
- A. Several dry, scaly patches on the face
- B. Numerous varicosities noted on both legs
- C. Dilation of small blood vessels on the face
- D. Petechiae present on the chest and abdomen
Correct Answer: D
Rationale: Petechiae are caused by pinpoint hemorrhages and are associated with inflammation, marked dilation, blood vessel trauma, and blood dyscrasias that result in bleeding tendencies (e.g., thrombocytopenia). The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes also will require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.
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 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.