Nokea
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.
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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.
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.
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 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.