Chapter 56: Integumentary System Introduction
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What should a nurse ask about when taking the functional assessment of a patient with a
skin disorder?
a. A sore that is slow to heal
b. Unusual hair growth
c. Previous skin disorders
d. Exposure to chemicals or irritants
ANS: D
The functional assessment is a search for clues in the occupation and lifestyle of the
patient: the other options are reference medical history and system review:
DIF: Cognitive Level: Application REF: p: 1103 OBJ: 3
TOP: Functional Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
2. A daughter of an older adult patient who has just returned from surgery is distressed
about her father’s pale, cold hands and feet: What is the best response by the nurse after
covering the patient with an extra blanket?
a. “Don’t be concerned: It is quite cold in the operating room: Your dad will be
warm in a minute:”
b. “Older patients like your dad get a little shocky during surgery:”
c. “When patients have blood loss during surgery, superficial vessels close off
temporarily, resulting in cold extremities:”
d. “We are watching the disturbed circulation in your dad’s hands and feet very
carefully:”
ANS: C
The 10% of the blood network that is in the skin can be reduced by constriction and
shunted to the vital organs:
DIF: Cognitive Level: Application REF: p: 1102 OBJ: 1
TOP: Skin Blood Reservoir KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What information should a nurse provide to a patient with vitiligo receiving
phototherapy?
a. “Expose yourself to the sun for several hours before treatment to acclimate the
skin surface:”
, b. “Wear protective clothing:”
c. “Wear loose clothing such as sleeveless T-shirts and shorts after the treatment:”
d. “Leave off sunglasses after treatment so your eyes can more quickly
accommodate:”
ANS: B
Eight hours before and after each treatment, the patient should wear protective
clothing, sunglasses, and sunscreen to decrease added ultraviolet exposure from other
sources:
DIF: Cognitive Level: Application REF: p: 1108 OBJ: 4
TOP: Phototherapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection
Control
4. A nurse is screening patients that the plastic surgeon is considering for phototherapy:
Which patient should the nurse exclude?
a. A 34-year-old woman with lupus erythematosus
b. A 5-year-old child with pneumonia
c. A 60-year-old man with a pacemaker
d. A 23-year-old woman who is 3 months’ pregnant
ANS: A
Persons with lupus erythematosus should avoid exposure to UV light:
DIF: Cognitive Level: Comprehension REF: p: 1108 OBJ: 4
TOP: Phototherapy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. Displaying her hands, a patient asks, “Do you think my liver is OK? Look at all these
liver spots!” What is the most appropriate nursing response?
a. “The spots could mean something is wrong; I will make a note of it:”
b. “The spots are normal aging changes and have nothing to do with your liver:”
c. “Have you recently been exposed to hepatitis?”
d. “Don’t worry about them: They will fade during the winter:”
ANS: B
Lentigines on sun-exposed areas are called liver spots because of their colour; they
have nothing to do with the liver or any disease process: They are normal changes of
aging:
DIF: Cognitive Level: Comprehension REF: p: 1106 OBJ: 2
TOP: Liver Spots KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation
6. A confused patient has been restrained because of combativeness and hyperactivity: What
skin assessment may occur as a result of the restraints?
, a. Lentigines
b. Senile purpura
c. Senile angiomas
d. Seborrheic keratoses
ANS: B
Purpura are purple bruises that resolve very slowly and are usually the result of minor
trauma:
DIF: Cognitive Level: Comprehension REF: p: 1106 OBJ: 2
TOP: Senile Purpura KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. Which conditions can be improved with negative pressure therapy? (Select all that apply:)
a. Pressure ulcers
b. Skin grafts
c. Burns
d. Dehisced surgical wounds
e. Eczema
ANS: A, B, D
All ulcers, skin grafts, and dehisced wounds respond well to negative pressure
therapy:
DIF: Cognitive Level: Comprehension REF: p: 1107 OBJ: 4
TOP: Negative Pressure Therapy KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. Which age-related skin changes should a nurse anticipate when performing a physical
assessment on an 80-year-old man? (Select all that apply:)
a. Increased nasal hair
b. Flattened nails
c. Small macular lesions at the hairline
d. Increased hair on the helix of the ear
e. Presence of seborrheic keratosis
ANS: A, B, D, E
Increased hair in the nostrils and ear, flattened discoloured nails, and seborrheic
keratosis are common age-related skin changes: Macular lesions are abnormal:
DIF: Cognitive Level: Knowledge REF: p: 1106 OBJ: 2
TOP: Age-Related Skin Changes KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
, COMPLETION
1. When assessing the capillary refill, a nurse should document as normal a refill time of
_______ seconds: (Use numeric characters only:)
ANS:
3
Capillary refill is a method of quick assessment of perfusion to the extremities: A
normal capillary refill time is 3 to 5 seconds or less:
DIF: Cognitive Level: Comprehension REF: p: 1103 OBJ: 3
TOP: Capillary Refill KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
2. A nurse collecting tissue for a Tzanck test should: ________ (Select the appropriate
interventions and place the steps in sequence: Do not separate answers with a space or
punctuation: Example: ABCD:)
a. Open the lesion with a hypodermic needle:
b. Place the specimen in a culture tube and take it to the laboratory:
c. Saturate the sterile swab with exudates:
d. Wash the lesion:
e. Place a pressure dressing on the lesion:
ANS:
DACB
The nurse washes the lesion, punctures the lesion with a needle, saturates a sterile
cotton swab, places the swab in a culture tube, and takes the collected tissue to the
laboratory: A pressure dressing is not needed:
DIF: Cognitive Level: Application REF: p: 1108 OBJ: 4
TOP: Tzanck Test KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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