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The nurse is performing a comprehensive assessment of a patients skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
- A. By examining the patient under a Woods light
- B. By inspecting the patients skin in direct sunlight
- C. By palpating the patients skin
- D. By performing percussion of major skin surfaces
Correct Answer: C
Rationale: Palpation assesses skin moisture, temperature, and texture. Woods light is for pigmentation, sunlight is impractical, and percussion is not used for skin assessment.
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A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply.
- A. Producing antibodies
- B. Absorbing electrolytes
- C. Maintaining acidbase balance
- D. Physically repelling pathogens
- E. Preventing fluid loss
Correct Answer: D,E
Rationale: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acidbase balance, or electrolyte levels.
Assessment of a patients leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
- A. Keloid
- B. Ulcer
- C. Fissure
- D. Erosion
Correct Answer: B
Rationale: An ulcer involves skin loss past the epidermis with necrotic tissue. Keloids are scar tissue, fissures are linear, and erosions are superficial.
The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?
- A. Cherry angiomas
- B. Solar lentigo
- C. Seborrheickeratoses
- D. Xanthelasma
Correct Answer: A
Rationale: Cherry angiomas are benign, bright red moles common in older adults. Solar lentigo are liver spots, seborrheickeratoses are crusty brown patches, and xanthelasma are yellowish deposits on the eyelids.
A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
- A. Vesicle
- B. Macule
- C. Nodule
- D. Wheal
Correct Answer: D
Rationale: A wheal is an elevated lesion with serous fluid in the dermis, such as a mosquito bite. Vesicles contain fluid but are circumscribed, macules are flat, and nodules are solid.
A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patients fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?
- A. Eczema
- B. Systemic lupus erythematosus (SLE)
- C. Psoriasis
- D. Chronic obstructive pulmonary disease (COPD)
Correct Answer: C
Rationale: Pitted nails are a hallmark of psoriasis. Eczema, SLE, and COPD do not typically cause nail pitting.