Nokea
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?
- A. Macules
- B. Papules
- C. Vesicles
- D. Pustules
Correct Answer: A
Rationale: Macules are flat, nonpalpable skin color changes. Papules are elevated and solid, vesicles contain serous fluid, and pustules are pus-filled.
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The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?
- A. An insect bite
- B. Dehydration
- C. Sunburn
- D. Excessive perspiration
Correct Answer: A
Rationale: An insect bite represents penetration of the skin by an environmental factor, breaching the stratum corneum. Dehydration, sunburn, and perspiration are not examples of penetration.
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.
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 nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patients health history, the nurse should identify what comorbidity as increasing the patients vulnerability to skin infections?
- A. Chronic obstructive pulmonary disease
- B. Rheumatoid arthritis
- C. Gout
- D. Diabetes
Correct Answer: D
Rationale: Diabetes increases susceptibility to skin infections like cellulitis due to impaired immune response and poor wound healing. COPD, rheumatoid arthritis, and gout are less directly related.
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.