Nokea
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.
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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 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.
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.
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.