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The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
- A. Is anyone in your family allergic to anything?
- B. How long have you had this abrasion?
- C. Do you take any over-the-counter drugs or herbal preparations?
- D. What do you do for a living?
Correct Answer: C
Rationale: Asking about over-the-counter drugs or herbal preparations can identify potential causes of a rash. Family allergy history, occupation, or mislabeling the rash as an abrasion are less immediately relevant.
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A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
- A. Telangiectasias
- B. Ecchymoses
- C. Purpura
- D. Urticaria
Correct Answer: B
Rationale: Ecchymoses are bruises, characterized by larger areas of blood extravasation under the skin. Telangiectasias are dilated superficial blood vessels, purpura are pinpoint hemorrhages, and urticaria are wheals or hives.
A nurse is providing an educational presentation addressing the topic of Protecting Your Skin. When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin?
- A. Islets of Langerhans
- B. Squamous cells
- C. T cells
- D. Melanocytes
Correct Answer: D
Rationale: Melanocytes produce melanin, the pigment responsible for skin color. Islets of Langerhans are pancreatic cells, squamous cells are epithelial, and T cells are immune cells.
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
- A. Decreased resistance to ultraviolet radiation
- B. Increased vulnerability to infection
- C. Diminished protection of tissues and organs
- D. Increased risk of skin malignancies
Correct Answer: C
Rationale: Loss of subcutaneous tissue reduces cushioning and insulation for underlying tissues and organs. It does not directly affect UV resistance, infection risk, or malignancy risk.
A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?
- A. Has she eaten any new foods today?
- B. Has she bathed in the past 24 hours?
- C. Did she go to a friends house today?
- D. Was she digging in the dirt today?
Correct Answer: A
Rationale: Food allergies are a common cause of urticaria in children. Bathing, visiting friends, or soil exposure are less likely to be relevant triggers.
A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation?
- A. Alopecia
- B. Yellowish skin tone
- C. Patchy, bronze pigmentation
- D. Hirsutism
Correct Answer: D
Rationale: Cushing syndrome causes hirsutism, especially in women, due to excess cortisol. Alopecia, yellowish skin, and bronze pigmentation are not typical features.