Chapter 22: Assessment of Integumentary System
Test Bank
MULTIPLE CHOICE
1. A 38-year-old female patient states that she is using topical fluorouracil
... [Show More] to treat actinic keratoses on her face.
Which additional assessment information will be most important for the nurse to obtain?
a. History of sun exposure by the patient
b. Method of birth control used by the patient
c. Length of time the patient has used fluorouracil
d. Appearance of the treated areas on the patients face
ANS: B
Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The
other information is also important for the nurse to obtain, but lack of reliable birth control has the most
potential for serious adverse medication effects.
DIF: Cognitive Level: Apply (application) REF: 399
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. Which integumentary assessment data from an older patient admitted with bacterial pneumonia is ofmost
concern for the nurse?
a. Reports a history of allergic rashes
b. Scattered macular brown areas on extremities
c. Skin brown and wrinkled, skin tenting on forearm
d. Longitudinal nail bed ridges noted; sparse scalp hair
ANS: A
Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned
about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic
rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data
in the other response would be normal for an older patient.
DIF: Cognitive Level: Apply (application) REF: 398
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle.
How should the nurse determine if the lesion is related to intradermal bleeding?
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 229
a. Elevate the patients leg.
b. Press firmly on the lesion.
c. Check the temperature of the skin around the lesion.
d. Palpate the dorsalis pedis and posterior tibial pulses.
ANS: B
If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will
remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching
will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful
in determining the etiology of the lesion.
DIF: Cognitive Level: Apply (application) REF: 401
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at
different stages of healing on the patients body. Which action should the nurse take first?
a. Discourage the use of throw rugs throughout the house.
b. Ensure the patient has a pair of shoes with non-slip soles.
c. Talk with the patient alone and ask about what caused the bruising.
d. Notify the health care provider so that x-rays can be ordered as soon as possible.
ANS: C
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different
stages of resolution. These may be indications of other health problems or abuse, and should be further
investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the
patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with
slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has
complaints of pain or decreased mobility. However, the nurses first nursing action is to further assess the
patient.
DIF: Cognitive Level: Apply (application) REF: 401
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
5. A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse
best assess this patient for cyanosis?
a. Assess the skin color of the earlobes.
b. Apply pressure to the palms of the hands.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 230
c. Check the lips and oral mucous membranes.
d. Examine capillary refill time of the nail beds.
ANS: C
Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change
in light-skinned individuals, but this change in skin color 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 color.
DIF: Cognitive Level: Apply (application) REF: 401
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which
items should the nurse gather for this procedure?
a. Sterile gloves
b. Patch test instruments
c. Cotton-tipped applicators
d. Local anesthetic, syringe, and intradermal needle
ANS: C
Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile
gloves are not needed because it is not a sterile procedure. Local injection is not needed because the swabbing
is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing
material, not for obtaining fungal specimens.
DIF: Cognitive Level: Apply (application) REF: 405
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
7. When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient.
Which action should the nurse take next?
a. Assess the patient for evidence of liver disease.
b. Discuss the adverse effects of sun exposure on the skin.
c. Teach the patient about possible skin changes with aging.
d. Suggest that the patient make an appointment with a dermatologist.
ANS: A
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 231
Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as
liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the
initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and
about the effects of sun exposure, but the initial action should be further assessment.
DIF: Cognitive Level: Apply (application) REF: 402
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
8. A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole
from the upper back. The nurse should prepare the patient for which type of biopsy?
a. Shave biopsy
b. Punch biopsy
c. Incisional biopsy
d. Excisional biopsy
ANS: C
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.
DIF: Cognitive Level: Apply (application) REF: 405
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. During assessment of the patients skin, the nurse observes a similar pattern of small, raised lesions on the
left and right upper back areas. Which term should the nurse use to document these lesions?
a. Confluent
b. Zosteriform
c. Generalized
d. Symmetric
ANS: D
The description of the lesions indicates that they are grouped. The other terms are inconsistent with the
description of the lesions.
DIF: Cognitive Level: Understand (comprehension) REF: 401
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
10. A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 232
finding will the nurse expect?
a. Hypertrophied scars on both ankles
b. Thickening of the skin around the ankles
c. Yellowish-brown skin around both ankles
d. Complete absence of melanin in both ankles
ANS: B
Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification
results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of
melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo,
keloids, and jaundice do not usually occur as a result of scratching the skin.
DIF: Cognitive Level: Understand (comprehension) REF: 402
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
11. Which abnormality on the skin of an older patient is the priority to discuss immediately with the health
care provider?
a. Several dry, scaly patches on the face
b. Numerous varicosities noted on both legs
c. Dilation of small blood vessels on the face
d. Petechiae present on the chest and abdomen
ANS: D
Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as
meningitis and coagulopathies. The nurse should contact the patients health care provider about this finding for
further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes
will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.
DIF: Cognitive Level: Apply (application) REF: 397
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. When taking the health history of an older adult, the nurse discovers that the patient has worked in the
landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which
clinical manifestations (select all that apply)?
a. Vitiligo
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 233
b. Alopecia
c. Intertrigo
d. Erythema
e. Actinic keratosis
ANS: D, E
A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema
and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure.
DIF: Cognitive Level: Analyze (analysis) REF: 397
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
2. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational
nurse (LPN/LVN) (select all that apply)?
a. Administer patch testing to a patient with allergic dermatitis.
b. Interview a new patient about chronic health problems and allergies.
c. Apply a sterile dressing after the health care provider excises a mole.
d. Teach a patient about site care after a punch biopsy of an upper arm lesion.
e. Explain potassium hydroxide testing to a patient with a superficial skin infection.
ANS: A, C
Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN
education and scope of practice. Obtaining a health history and patient education require more critical thinking
and registered nurse (RN) level education and scope of practice.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 234
Chapter 23: Integumentary Problems
Test Bank
MULTIPLE CHOICE
1. Which information should the nurse include when teaching patients about decreasing the risk for sun
damage to the skin?
a. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection.
b. Water resistant sunscreens will provide good protection when swimming.
c. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
d. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).
ANS: D
The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is
completely water resistant. Sunscreens classified as water resistant sunscreens still need to be reapplied after
swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer.
Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not
decreased.
DIF: Cognitive Level: Apply (application) REF: 408
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
2. Which information should the nurse include when teaching a patient who has just received a prescription for
ciprofloxacin (Cipro) to treat a urinary tract infection?
a. Use a sunscreen with a high SPF when exposed to the sun.
b. Sun exposure may decrease the effectiveness of the medication.
c. Photosensitivity may result in an artificial-looking tan appearance.
d. Wear sunglasses to avoid eye damage while taking this medication.
ANS: A
The patient should stay out of the sun. If that is not possible, teach them to wear sunscreen when taking
medications that can cause photosensitivity. The other statements are not accurate.
DIF: Cognitive Level: Apply (application) REF: 409
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
3. A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which
information should the nurse include in the teaching plan?
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 235
a. Treatment plans include watchful waiting.
b. Screening for metastasis will be important.
c. Low dose systemic chemotherapy is used to treat BCC.
d. Minimizing sun exposure will reduce risk for future BCC.
ANS: D
BCC is frequently associated with sun exposure and preventive measures should be taken for future sun
exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue
destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.
DIF: Cognitive Level: Apply (application) REF: 411
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action
should the nurse take?
a. Prepare the patient for a biopsy.
b. Teach about the use of corticosteroid creams.
c. Explain how to apply tretinoin (Retin-A) to the face.
d. Discuss the need for topical application of antibiotics.
ANS: A
Because the appearance of the lesion suggests actinic keratosis or possible squamous cell carcinoma (SCC), the
appropriate treatment would be excision and biopsy. Over-the-counter (OTC) corticosteroids, topical
antibiotics, and Retin-A would not be used for this lesion.
DIF: Cognitive Level: Apply (application) REF: 411
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the
priority focus of patient teaching?
a. The patient has multiple dysplastic nevi.
b. The patient is fair-skinned and has blue eyes.
c. The patients mother died of a malignant melanoma.
d. The patient uses a tanning booth throughout the winter.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 236
ANS: D
Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus
teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for
melanoma.
DIF: Cognitive Level: Apply (application) REF: 408
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
6. The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower
face. Which instructions should the nurse include in the teaching plan?
a. Clean the infected areas with soap and water.
b. Apply alcohol-based cleansers on the lesions.
c. Avoid use of antibiotic ointments on the lesions.
d. Use petroleum jelly (Vaseline) to soften crusty areas.
ANS: A
The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water
removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic
ointments, such as mupirocin (Bactroban), may be applied to the lesions.
DIF: Cognitive Level: Apply (application) REF: 414
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. The nurse notes the presence of white lesions that resemble milk curds in the back of a patients throat.
Which question by the nurse is appropriate at this time?
a. Do you have a productive cough?
b. How often do you brush your teeth?
c. Are you taking any medications at present?
d. Have you ever had an oral herpes infection?
ANS: C
The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in
patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated
with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection.
DIF: Cognitive Level: Apply (application) REF: 416
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 237
8. A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which
assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to
prevent the spread of pediculosis?
a. Ringlike rashes with red, scaly borders over the entire scalp
b. Papular, wheal-like lesions with white deposits on the hair shaft
c. Patchy areas of alopecia with small vesicles and excoriated areas
d. Red, hivelike papules and plaques with sharply circumscribed borders
ANS: B
Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft.
The other descriptions are more characteristic of other types of skin disorders.
DIF: Cognitive Level: Understand (comprehension) REF: 417
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The
nurse should include which statement in the patients instructions?
a. 5-FU will shrink the lesion so that less scarring occurs once the lesion is excised.
b. You may develop nausea and anorexia, but good nutrition is important during treatment.
c. You will need to avoid crowds because of the risk for infection caused by chemotherapy.
d. Your cheek area will be painful and develop eroded areas that will take weeks to heal.
ANS: D
Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of
the medication is stopped. The medication is topical, so there are no systemic effects such as increased
infection risk, anorexia, or nausea.
DIF: Cognitive Level: Apply (application) REF: 421
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several
weeks. The nurse should assess for which adverse effect?
a. Thinning of the affected skin
b. Alopecia of the affected areas
c. Reddish-brown discoloration of the skin
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 238
d. Dryness and scaling in the areas of treatment
ANS: A
Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring.
The health care provider should be notified so that the medication can be changed or tapered. Alopecia, redbrown discoloration, and dryness/scaling of the skin are not adverse effects of topical corticosteroid use.
DIF: Cognitive Level: Apply (application) REF: 421
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
11. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What
action should the nurse take to prevent adverse effects from this procedure?
a. Cleanse the skin carefully with an antiseptic soap.
b. Shield any unaffected areas with lead-lined drapes.
c. Have the patient use protective eyewear while receiving PUVA.
d. Apply petroleum jelly to the areas surrounding the psoriatic lesions.
ANS: C
The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development
of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes,
use of antiseptic soap, and petroleum jelly are not used to prevent skin damage.
DIF: Cognitive Level: Apply (application) REF: 420
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
12. A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment.
The nurse should plan to prepare the patient for which procedure?
a. Curettage
b. Cryosurgery
c. Punch biopsy
d. Surgical excision
ANS: D
The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and
cryosurgery are not used if malignancy is suspected. A punch biopsy would not be done for a lesion greater
than 5 mm in diameter.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 239
DIF: Cognitive Level: Apply (application) REF: 410
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. Which information will the nurse include when teaching an older patient about skin care?
a. Dry the skin thoroughly before applying lotions.
b. Bathe and wash hair daily with soap and shampoo.
c. Use warm water and a moisturizing soap when bathing.
d. Use antibacterial soaps when bathing to avoid infection.
ANS: C
Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin,
daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are
not necessary. Lotions should be applied while the skin is still damp to seal moisture in.
DIF: Cognitive Level: Apply (application) REF: 410
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
14. What is the best method to prevent the spread of infection when the nurse is changing the dressing over a
wound infected with Staphylococcus aureus?
a. Change the dressing using sterile gloves.
b. Soak the dressing in sterile normal saline.
c. Apply antibiotic ointment over the wound.
d. Wash hands and properly dispose of soiled dressings.
ANS: D
Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of
skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of
infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of
infection.
DIF: Cognitive Level: Apply (application) REF: 424
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
15. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient
teaching?
a. The patient applies corticosteroid cream to pruritic areas.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 240
b. The patient uses Neosporin ointment on minor cuts or abrasions.
c. The patient adds oilated oatmeal (Aveeno) to the bath water every day.
d. The patient takes diphenhydramine (Benadryl) at night if itching occurs.
ANS: B
Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient.
DIF: Cognitive Level: Apply (application) REF: 421
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
16. The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass
index of 40 kg/m2. What is the nurses best action?
a. Teach the patient about the treatment of fungal infection.
b. Discuss the use of drying agents to minimize infection risk.
c. Instruct the patient about the use of mild soap to clean skinfolds.
d. Ask the patient about type 2 diabetes or if there is a family history of it.
ANS: D
The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an
increased risk for it. The description of the patients skin does not indicate problems with fungal infection, poor
hygiene, or the need to dry the skinfolds better.
DIF: Cognitive Level: Apply (application) REF: 410
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
17. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick,
brittle nails. What is the nurses best action?
a. Instruct the patient about the importance of nutrition in skin health.
b. Make a referral to a podiatrist so that the nails can be safely trimmed.
c. Consult with the health care provider about the need for further diagnostic testing.
d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.
ANS: C
The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 241
hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the
patients dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying
disease that may be causing these manifestations.
DIF: Cognitive Level: Apply (application) REF: 420
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
18. An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in
the dermatology clinic. Which nursing action will be included in the postoperative plan of care?
a. Describe the use of topical fluorouracil on the incision.
b. Teach how to use sterile technique to clean the suture line.
c. Schedule daily appointments for wet-to-dry dressing changes.
d. Teach about the use of cold packs to reduce bruising and swelling.
ANS: D
Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site.
Since the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after
surgery. After the Mohs procedure the edges of the wound can be left open to heal or the edges can be
approximated and sutured together. The suture line can be cleaned with tap water. No debridement with wetto-dry dressings is indicated.
DIF: Cognitive Level: Apply (application) REF: 424
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
19. A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient
about the medication, which statement by the patient indicates that further teaching is needed?
a. After I apply the medication, I can go ahead and get dressed as usual.
b. I will need to minimize my time in the sun while I am using the Elidel.
c. I will rub the medication gently onto the skin every morning and night.
d. If the medication burns when I apply it, I will wipe it off and call the doctor.
ANS: D
The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus
and that the medication should be left in place. The other statements by the patient are accurate and indicate
that patient teaching has been effective.
DIF: Cognitive Level: Apply (application) REF: 422
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 242
20. The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on
the right leg. Which patient action indicates that further teaching is needed?
a. The patient takes a tepid bath before applying the cream.
b. The patient spreads the cream using a downward motion.
c. The patient applies a thick layer of the cream to the affected skin.
d. The patient covers the area with a dressing after applying the cream.
ANS: C
Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by
the patient indicate that the teaching has been successful.
DIF: Cognitive Level: Apply (application) REF: 423
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
21. The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse
delegate to unlicensed assistive personnel (UAP)?
a. Applying antibiotic cream to the groin.
b. Obtaining cultures from ruptured lesions.
c. Evaluating the patients personal hygiene.
d. Cleaning the skin with antimicrobial soap.
ANS: D
Cleaning the skin is within the education and scope of practice for UAP. Administration of medication,
obtaining cultures, and evaluation are higher-level skills that require the education and scope of practice of
licensed nursing personnel.
DIF: Cognitive Level: Apply (application) REF: 426
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
22. The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a
blepharoplasty. Which assessment data should be reported to the surgeon immediately?
a. The patient complains of incisional pain.
b. The patients heart rate is 110 beats/minute.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 243
c. The patient is unable to detect when the eyelids are touched.
d. The skin around the incision is pale and cold when palpated.
ANS: D
Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The
other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110
beats/minute may be related to the stress associated with surgery. Assessment of other vital signs and
continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of
the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.
DIF: Cognitive Level: Apply (application) REF: 426
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
23. A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn
because of the appearance of the lesions. Which action should the nurse take first?
a. Discuss the possibility of enrolling in a worker-retraining program.
b. Encourage the patient to volunteer to work on community projects.
c. Suggest that the patient use cosmetics to cover the psoriatic lesions.
d. Ask the patient to describe the impact of psoriasis on quality of life.
ANS: D
The nurses initial actions should be to assess the impact of the disease on the patients life and to allow the
patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be
appropriate.
DIF: Cognitive Level: Apply (application) REF: 424
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
24. The nurse working in the dermatology clinic assesses a young adult female patient who is taking
isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for
further questioning of the patient?
a. The patient recently had an intrauterine device removed.
b. The patient already has some acne scarring on her forehead.
c. The patient has also used topical antibiotics to treat the acne.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 244
d. The patient has a strong family history of rheumatoid arthritis.
ANS: A
Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The
nurse will need to determine whether the patient is using other birth control methods. More information about
the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin
use.
DIF: Cognitive Level: Apply (application) REF: 418
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
25. There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments
today. Which patient will the nurse schedule for the available opening?
a. 38-year old with a 7-mm nevus on the face that has recently become darker
b. 62-year-old with multiple small, soft, pedunculated papules in both axillary areas
c. 42-year-old with complaints of itching after using topical fluorouracil on the nose
d. 50-year-old with concerns about skin redness after having a chemical peel 3 days ago
ANS: A
The description of the lesion is consistent with possible malignant melanoma. This patient should be assessed
as soon as possible by the health care provider. Itching is common after using topical fluorouracil and redness
is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife.
DIF: Cognitive Level: Analyze (analysis) REF: 410
OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus.
Which information should the nurse include in the teaching plan (select all that apply)?
a. Cool, wet cloths or dressings can be used to reduce itching.
b. Take cool or tepid baths several times daily to decrease itching.
c. Add oil to your bath water to aid in moisturizing the affected skin.
d. Rub yourself dry with a towel after bathing to prevent skin maceration.
e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 245
ANS: A, B, E
Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil
to bath water is not recommended because of the increased risk for falls. The patient should use the towel to
pat (not rub) the skin dry.
DIF: Cognitive Level: Analyze (analysis) REF: 423
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 246 [Show Less]