The nurse is assessing a white patient's skin color and notices cyanosis. Where on the patient's body would the nurse most likely see this cyanosis?
Lips
Legs
Wrists
Sclera Correct Answer-Lips
On light-skinned individuals, cyanosis, or grayish blue tone, initially appears in lips,...
NURS 3107 - Exam 4 - EAQs: Integumentary
Assessment questions with correct answers
The nurse is assessing a white patient's skin color and notices cyanosis.
Where on the patient's body would the nurse most likely see this
cyanosis?
Lips
Legs
Wrists
Sclera Correct Answer-Lips
On light-skinned individuals, cyanosis, or grayish blue tone, initially
appears in lips, nail beds, earlobes, mucous membranes, palms of the
hands, and soles of the feet. It is not as likely on the legs, wrists, or
sclera.
On assessment, a linear crack from the epidermis to the dermis is noted
at the corner of the patient's mouth. How should the nurse document this
finding?
Scar
,Fissure
Atrophy
Excoriation Correct Answer-Fissure
The secondary skin lesion, called a fissure, is a linear crack or break
from the epidermis to the dermis and can be dry as in athlete's foot or
moist as in cracks at the corner of the mouth. A scar is an abnormal
formation of connective tissue that replaces normal skin when a wound
heals. Atrophy is a depression in skin resulting from thinning of the
epidermis or dermis. Excoriation is an area in which the epidermis is
missing, which exposes dermis (e.g., abrasion or scratch).
To obtain information about temperature, turgor, moisture, and texture,
which assessment technique should the nurse use?
Inspection of skin color
Examination for vascularity
Palpation of skin with the hand
Percussion of the skin on the back Correct Answer-Palpation of skin
with the hand
,Palpation of the skin with the back of the hand will assess temperature.
Turgor is assessed by gently pinching the skin on the back of the hand
and observing its return to original position when released. Moisture and
texture of skin is assessed by touching it to assess it. Percussion does not
assess the skin, but the organs beneath the skin.
To assess the skin turgor, the most appropriate technique for the nurse to
use is which of these?
Palpation
Inspection
Percussion
Auscultation Correct Answer-Palpation
Turgor refers to the elasticity of the skin. Assess turgor by gently
pinching an area of skin under the clavicle or on the back of the hand.
Skin with good turgor should move easily when lifted and should
immediately return to its original position when released. Inspection,
percussion, and auscultation are not useful for assessing skin turgor.
, The patient has diffuse distribution of moles on the body. A biopsy of
one on the patient's back will be done to assess for malignancy. The
nurse knows that what is the rationale for doing a punch biopsy?
It is used for a superficial lesion.
It provides a full-thickness of skin.
It is used for good cosmetic results.
It is used because the lesion is too large to remove. Correct Answer-It
provides a full-thickness of skin.
The punch biopsy provides full-thickness skin for diagnostic purposes.
A shave biopsy is used for a superficial lesion or when only a small
sample is needed for diagnostic purposes. An excisional biopsy is used
when a good cosmetic result is desired. An incisional biopsy is a wedge-
shaped incision made in a lesion that is too large for an excisional
biopsy. It is useful when a larger specimen is needed than a shave or
punch biopsy can provide.
During the change-of-shift report, the outgoing nurse reports a new
finding of petechiae in a new patient admitted with a yet-to-be diagnosed
hematologic disorder. On assessment of this patient, what should the
incoming nurse expect to find?
Tiny, purple spots on the skin
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