Test Bank: Integumentary Function Meiner: Gerontologic Nursing, 6th Edition
MULTIPLE CHOICE
1. The nurse explains that the plan of care for an
... [Show More] older adult patient with seborrheic dermatitis of the scalp should include which actions?
a. Cleaning lesions with a weak hydrogen peroxide solution daily
b. Cleaning the scalp with a low-dose steroidal shampoo
c. Applying hydrocortisone 10% to scalp lesions
d. Applying selenium shampoo to the scalp
ANS: D
A successful strategy is to wet the hair, apply selenium shampoo, and then proceed with the rest of the bath or shower. The other measures will not be successful.
DIF: Understanding OBJ: 17-3 TOP: Integrated Process: Teaching-Learning
MSC: Physiologic Integrity
2. An older adult patient reports pruritus. The nurse educates the patient on the importance of which action?
a. Applying a lanolin-rich cream and avoiding scratching the areas
b. Taking warm baths and gently rubbing of affected areas with a terrycloth towel
c. Minimizing ingestion of fried foods and use of an antihistamine cream
d. Avoiding bath oils andNalUloRwSinIg NthGe TskBin.tCo OaiMr-dry after bathing
ANS: A
The nurse suggests that the patient apply emollients (e.g., Lubriderm, Moisturel, or Eucerin lotion or cream), which have more lanolin or oily substances than many commercial lotions. Time should be planned to teach the patient and family about etiologic factors and the importance of not scratching. The other options are not helpful and will not decrease the itching.
DIF: Understanding OBJ: 17-3 TOP: Integrated Process: Teaching-Learning
MSC: Health Promotion and Maintenance
3. The nurse plans to assess for candidiasis as a priority intervention for which patient?
a. 60-year-old with a history of bacterial pneumonia
b. 72-year-old incontinence of urine and feces
c. 58-year-old with a casted left foot
d. 90-year-old receiving antihypertensives
ANS: B
Candidiasis is most commonly seen in diaper-clad infants, incontinent patients, and
bed-bound individuals and in moisture-prone areas of the body (e.g., skin folds and axillae). The other patients are not as likely to have this disorder as the incontinent patient.
DIF: Understanding OBJ: 17-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. An 87-year-old patient developed herpes zoster after surgical repair of a hip fracture. The priority nursing diagnosis is
a. impaired skin integrity related to immunologic deficit.
b. self-care deficit related to severe pain and fatigue.
c. risk for infection related to impaired skin integrity.
d. pain related to inadequate pain relief from analgesia.
ANS: C
These vesicles are extremely vulnerable to secondary bacterial infections. The other diagnoses might be appropriate for some patients.
DIF: Applying OBJ: 17-3 TOP: Nursing Process: Diagnosis MSC: Physiologic Integrity
5. The presence of which skin assessment finding should cause the nurse to suspect a premalignancy?
a. Numerous small red papules on the chest and back
b. A rough, reddish macule on the ear
c. An irregularly shaped mole on the shoulders
d. Brown, greasy lesions on the neck
ANS: B
Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. Actinic keratosis may evolve into
squamous cell carcinoma (SCUC)Sif nNot trTeated, sOo it should receive prompt attention. Red
papules, irregularly shaped moles, and brown greasy lesions are not likely to be precancerous.
DIF: Understanding OBJ: 17-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An older adult patient has been taught measures to prevent the development of skin cancer. Which statement, if made by the patient, indicates the need for more teaching?
a. “I will certainly miss my vegetable and flower gardening.”
b. “I should buy a sunscreen with an SPF of 15 or higher.”
c. “Now I have a good excuse to wear the straw hat my spouse hates.”
d. “My cool long-sleeved shirts will work just fine while I’m golfing.”
ANS: A
The patient is still able to garden as long as he or she takes appropriate sun precautions. The other statements show good understanding.
DIF: Evaluating OBJ: 17-4 TOP: Nursing Process: Evaluation MSC: Health Promotion and Maintenance
7. When assessing the older adult patient’s skin, what finding would indicate the need to notify the provider as the priority?
a. Thick, adherent scale with a soft center
b. Small, inflamed lesion that bleeds easily
c. Irregularly shaped multicolored mole
d. Small, purple, hard nodule beneath the skin surface
ANS: C
Melanoma’s clinical hallmark is an irregularly shaped nevus (mole), papule, or plaque that has undergone a change, particularly in color. The other options do not display the characteristic signs of melanoma. This patient has the highest need for the nurse to communicate with the provider.
DIF: Remembering OBJ: 17-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. An older adult patient newly diagnosed with peripheral vascular disease (PVD). What assessment finding indicates the patient may have an arterial ulcer resulting from this disease?
a. Deep, necrotic, and painless sore
b. Shiny, dry, cyanotic skin surrounding the ulcer
c. Ulcer appears shallow, crusty with warm skin
d. Sore that has dull pain and is oozing
ANS: B
As the disease advances, the extremity develops a cyanotic hue and becomes cool. The skin becomes thin, shiny, and dry and has an associated loss of hair and thickened nails, all of which results from the diminished blood supply. This assessment finding indicates an
arterial ulcer.
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DIF: Remembering OBJ: 17-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
9. An older adult patient has an open, draining wound on the lower medial aspect of the right leg. The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based on this information, the nurse edits the patient’s care plan to include impaired skin integrity related to which factor?
a. Altered venous circulation
b. Arterial insufficiency
c. Diabetic neuropathy
d. Pressure ulcer
ANS: A
Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is no indication the patient is a diabetic. There is no indication the patient has risks for pressure ulcers.
DIF: Applying OBJ: 17-11 TOP: Nursing Process: Analysis MSC: Physiologic Integrity
10. When assessing for squamous cell cancer (SCC), a home health nurse is particularly concerned about which suspicious lesion?
a. Leg of a 60-year-old Asian female
b. Neck of a 73-year-old Hispanic female
c. Lower lip of a 70-year-old African American male
d. Back of a 90-year-old Caucasian male
ANS: C
SCC is skin cancer arising from the epidermis and is found most often on the scalp, outer ears, lower lip, and dorsum of the hands. Approximately 90% of lip lesions can be attributed to squamous cell carcinoma. SCC is more common in men and older adults. SCC is the most common skin cancer in African Americans.
DIF: Remembering OBJ: 17-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse educates the patient to the possibility of developing which other manifestation?
a. Alopecia
b. Orange-tinged urine
c. Yellow-brown nails
d. Cherry angiomas
ANS: C
Changes in the nails occur in approximately 30% of patients and consist of yellow-brown
discoloration with pitting, dNimpRlinIg, seGparBat.ioCn ofMthe nail plate from the underlying bed
(onycholysis), thickening, anUd crSumbNlinTg. O
DIF: Understanding OBJ: 17-3 TOP: Integrated Process: Teaching-Learning
MSC: Physiologic Integrity
12. The nurse of a bedridden 74-year-old woman is evaluating whether the family members understand how to position the patient correctly. The nurse is confident the family is capable of effective positioning when it is observed that the family members perform which action?
a. Support the arms and legs on two pillows.
b. Turn the patient at least every 2 hours.
c. Hyperflex the neck using pillows
d. Rest elbows on the bed with lower arms elevated.
ANS: B
In the 1950s, Kosiak (1958) found that pressure applied to rabbits’ ears over 2 hours would result in ulceration. Thus the universal recommendation of turning every 2 hours was established. The family should turn the patient at least every 2 hours, more often if the
patient’s skin shows signs of pressure injury during that timeframe. The other actions are not proper positioning techniques.
DIF: Evaluating OBJ: 17-6 TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
13. An older diabetic patient reports a candidiasis infection. When asked, the patient states all blood sugars have been within the target range. What action by the nurse is best?
a. Facilitate having a hemoglobin A1C drawn.
b. Teach the patient preventive measures.
c. Teach the patient about the side effects of medications.
d. Review the patient’s medication history.
ANS: A
Often candidiasis infections in diabetics indicate hyperglycemia. The patient may or may not be truthful about the blood sugar reports, or the patient may be missing periods of hyperglycemia when testing. The nurse should consult with the provider about checking an A1C. The other options are appropriate as well but do not give information as to the background cause.
DIF: Applying OBJ: 17-3 TOP: Nursing Process: Assessment MSC: Physiologic Integrity
14. An older patient has been treated for a small basal cell carcinoma on the face. What assessment finding indicates to the nurse that the goals for a priority diagnosis have been met?
a. The patient verbalizes relief there is no metastasis.
b. Wound edges are approximated without redness.
c. The patient expresses satisfaction with the cosmetic outcome.
d. The patient relates the need for proper sun protection.
ANS: B
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All findings indicate positive resolution of various nursing diagnoses. However, physical diagnoses take priority, so the best response is the one that indicates lack of infection.
DIF: Evaluating OBJ: 17-4 TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
15. In creating community education on various types of skin cancer, the nurse places the highest priority on early diagnosis of melanoma because
a. it accounts for the largest number of mortalities.
b. extensive surgery can be avoided if caught early.
c. once it has spread there is no chance of curing it.
d. it is the most commonly occurring skin cancer.
ANS: A
Melanoma is a malignant neoplasm of pigment-forming cells that is capable of metastasizing to any organ of the body, even before the lesion is noted; therefore early detection is crucial. Therefore it is critical that the condition is diagnosed promptly. Basal cell carcinoma is the most common type of skin cancer.
DIF: Remembering OBJ: 17-4 TOP: Integrated Process: Teaching-Learning
MSC: Health Promotion and Maintenance
16. An older diabetic patient has impaired mobility and decreased vision. The nurse examines
the patient’s feet at each clinical visit. The patient asks why this is necessary. What response by the nurse is best?
a. “It’s part of our diabetic clinic visit protocol.”
b. “You may not be able to see a sore on your feet.”
c. “Limited mobility may keep you from checking your feet.
d. “You may get an ulcer and not be able to feel it.”
ANS: D
A diabetic with peripheral neuropathy may not be able to feel injuries on the feet. The injury may progress to a nonhealing ulcer requiring amputation. If the patient had good sensation to the feet, not being able to see or limited mobility would not be as big of a barrier because the patient could report the symptoms. Foot assessment is part of a diabetic clinic protocol but that answer does not educate the patient.
DIF: Analyzing OBJ: 17-3 TOP: Integrated Process: Teaching-Learning MSC: Physiologic Integrity
17. For which patient does the nurse add compression therapy to the nursing care plan?
a. Taut, white, shiny skin
b. Faint pedal pulses
c. Brownish skin and edema
d. Large ulcer with skin graft
ANS: C
Compression is the mainstay of venous ulcer treatment, and it should be applied when there is brownish skin and edema. The taut white shiny skin and faint pulses indicate arterial
insufficiency, and compressiUon wSill NcomTpromisOe circulation in those extremities even
further. A skin graft needs to be protected, as it is vulnerable until healed.
DIF: Analyzing OBJ: 17-11 TOP: Nursing Process: Planning MSC: Physiologic Integrity
18. The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is most important to add to the patient’s care plan?
a. Encourage high-protein meals and snacks.
b. Turn the patient every to 2 hours.
c. Assess the patient’s skin daily.
d. Monitor patient’s prealbumin weekly.
ANS: B
A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most important intervention is to turn the patient frequently. Good nutrition is important for wound healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately impact the patient’s skin condition. Assessing the skin will not prevent an ulcer.
DIF: Applying OBJ: 17-6 TOP: Nursing Process: Planning MSC: Physiologic Integrity
19. A patient has a purulent, foul-smelling tunneling leg wound. What wound care practice is most appropriate?
a. Leave the wound open to the air.
b. Administer systemic antibiotics.
c. Pack the wound with iodine-impregnated gauze.
d. Prepare the patient for operative debridement.
ANS: C
Antiseptics are not used on healthy granulating tissue. Iodine-impregnated gauze can be packed into the tunnels of this infected wound. A moist environment is needed for healing; leaving the wound open to air will cause too much drying. The patient may eventually need operative debridement. Systemic antibiotics may or may not be needed.
DIF: Applying OBJ: 17-10 TOP: Nursing Process: Implementation MSC: Physiologic Integrity
20. A patient has a wound that is a shallow lesion with a red, moist wound bed. What stage pressure ulcer does the nurse chart?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. The wound bed is pink or red and moist. A stage I pressure ulcer is redness or mottled skin that does not blanch. Stage III uNlcerRs arIe fuGll thBic.kCnessMdeep craters. Stage IV ulcers may extend
into the fascia and may be neUcrotSic. N T O
DIF: Remembering OBJ: 17-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse knows that several age-related changes in the integumentary system increase older adults’ risk for pressure ulcers. Which factors does this include? (Select all that apply.)
a. Poor nutrition
b. Living in a nursing home
c. Thinning epidermis
d. Decreased skin elasticity
e. Vessel degeneration
ANS: C, D, E
Thinning epidermis, decreased elasticity of the skin, and deterioration of the vasculature are all age-related changes increasing risk of pressure ulcer development. Poor nutrition and living in a nursing home are not expected age-related changes.
DIF: Remembering OBJ: 17-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity [Show Less]