Nokea
When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
- A. The scalp
- B. The elbows
- C. The palms of the hands
- D. The knees
Correct Answer: C
Rationale: The epidermis is the thickest over the palms of the hands and the soles of the feet, providing greater protection in these high-contact areas.
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A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?
- A. Obtain a swab for culture.
- B. Assess the characteristics of the lesion.
- C. Obtain a swab for pH testing.
- D. Apply a test dose of broad-spectrum topical antibiotic.
Correct Answer: B
Rationale: Assessing and documenting the characteristics of an open lesion is the priority to guide further diagnostics or treatment. Culture, pH testing, or antibiotics should follow assessment.
A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patients susceptibility to heat loss is related to atrophy of what skin component?
- A. Epidermis
- B. Merkel cells
- C. Dermis
- D. Subcutaneous tissue
Correct Answer: D
Rationale: Subcutaneous tissue, with its fat content, insulates against heat loss. Atrophy in patients with low BMI increases hypothermia risk. The epidermis, Merkel cells, and dermis do not primarily regulate temperature.
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.
A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?
- A. Is the rash worse at a particular time or season?
- B. Are you allergic to any foods or medication?
- C. Are you having any loss of sensation in that area?
- D. Is your rash painful?
Correct Answer: B
Rationale: A new rash during antibiotic therapy suggests a possible allergic reaction, which could be life-threatening. Assessing for allergies is the priority over timing, sensation, or pain.
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
- A. Elbows
- B. Lips
- C. Nail beds
- D. Sclerae
Correct Answer: D
Rationale: Jaundice, caused by elevated serum bilirubin, is best observed in the sclerae and mucous membranes, especially in darker-skinned individuals where skin pigmentation may mask changes.