Test Bank Unit 15 : Understanding Medical-Surgical Nursing 6th Edition Linda S. Williams Paula D. Hopper ||Chapter 53 - 55
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Course
Medical Surgical Nursing
Institution
Medical Surgical Nursing
Test Bank Unit 15: Understanding Medical-Surgical Nursing
6th Edition Linda S. Williams Paula D. Hopper
Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
MULTIPLE CHOICE
1. The nurse is assisting with a skin examination for a patient. The patient asks, “I love ...
Test Bank Unit 15: Understanding Medical-Surgical Nursing
6th Edition Linda S. Williams Paula D. Hopper
Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
MULTIPLE CHOICE
1. The nurse is assisting with a skin examination for a patient. The patient asks, “I love the sun,
why is everyone so concerned about sun exposure?” Which answer by the nurse is best?
1. “Sun exposure will cause the skin to age and wrinkle.”
2. “The sun gives off ultraviolet (UV) rays that destroy vitamin D.”
3. “Melanin pigment is a barrier against UV exposure.”
4. “UV rays are mutagenic and can cause skin cancers.”
ANS: 4
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Explain normal structures and functions of the integumentary system.
Page: 1147
Heading: Epidermis, Dermis, and Hypodermis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
Feedback
1 Sun exposure can contribute to skin aging and the development of wrinkles;
however, this is not the best answer regarding sun exposure.
2 The sun gives off UV rays, but UV rays are not involved in the destruction of
vitamin D.
3 When melanin cells are stimulated by exposure to the sun, more pigment is
produced to form a barrier against UV exposure to living cells in the stratum
germinativum. The visible result is a tan.
4 The best answer about concern related to sun exposure is that UV rays are
mutagenic and can damage the DNA in cells, create mutations, and cause skin
malignancies.
PTS: 1 CON: Tissue Integrity
2. The nurse in a health care provider’s (HCP’s) office is reassessing a patient’s skin and
making a comparison with the information from the patient’s last visit. For which reason
does the nurse focus on any changes noted in the patient’s skin?
1. Detection of skin cancer early can improve chances of a cure.
2. The skin is a good communicator regarding the patient’s health.
3. Skin lesions are seen as solid predictors of general health state.
4. The patient’s psychological health is best predicted by the skin.
ANS: 2
, Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: List data to collect when caring for a patient with an integumentary system
disorder.
Page: 1148
Heading: Nursing Assessment of the Integumentary System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
Feedback
1 Skin cancer can be detected early with regular skin inspections; however, the
nurse’s focus on changes is not just related to skin cancer.
2 The nurse knows the condition of the skin can be caused by underlying
systemic conditions or manifestations of issues just related to the skin. Both
situations make it important for the nurse to focus on changes from the last
examination.
3 Skin lesions are not solid predictors of a patient’s general health issues. Some
skin lesions are just indications of skin problems.
4 Psychological stress can contribute to a patient’s skin condition; however, this
connection varies among individuals.
PTS: 1 CON: Tissue Integrity
3. The nurse is preparing to reexamine the skin of a patient who has a history of malignant skin
growths. Which preparation by the nurse is incorrect?
1. Allow the patient to leave on underwear and socks.
2. Plan to use the techniques of inspection and palpation.
3. Include the hair, nails, scalp, and mucous membranes.
4. Explain the need for a penlight and magnifying glass.
ANS: 1
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: List data to collect when caring for a patient with an integumentary system
disorder.
Page: 1149
Heading: Physical Examination
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
Feedback
1 The patient needs to completely undress for a thorough inspection, especially
with a history of malignant skin growths. The feet and genitalia are not immune
, to skin lesions or cancers.
2 When reassessing the patient’s skin, the nurse will use the techniques of
inspection and palpation.
3 The body skin is not the only area inspected during a skin examination; the
hair, nails, scalp, and mucous membranes are also inspected.
4 The nurse needs to explain the need for a penlight and magnifying glass during
a skin inspection; some areas of concern may be very small or in areas hidden
by other parts of the body.
PTS: 1 CON: Tissue Integrity
4. The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion.
Which assessment finding causes the nurse the most concern?
1. Edema formation
2. Dry, macerated skin
3. Increased lesion oozing
4. Excessive skin oiliness
ANS: 2
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Describe therapeutic measures that are used for patients with integumentary
disorders.
Page: 1150
Heading: Open Wet Dressings
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Moderate
Feedback
1 Edema is not a common reaction to wet dressings.
2 Wet dressings should not be prescribed for more than 72 hours, because the
skin may become too dry or macerated.
3 Oozing is not a common reaction to wet dressings.
4 Oiliness is not a common reaction to wet dressings.
PTS: 1 CON: Tissue Integrity
5. The nurse works in an extended-care facility and is assisting in the development of a policy
and procedure addressing foot care of the residents. Which intervention does the nurse
identify as needing to be reconsidered in regard to routine foot care?
1. Soak the residents’ feet briefly in warm water and wash with gentle soap.
2. Use gauze or pads to reduce pressure where toes lie across each other.
3. Use a pumice stone to remove dry skin from heels or callused areas.
4. Apply an alcohol-free lotion to massage and perform range of motion (ROM) on
feet and ankles.
, ANS: 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify the effects of aging on the integumentary system.
Page: 1181
Heading: Care of Older Patients’ Feet
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Tissue Integrity
Difficulty: Difficult
Feedback
1 Soaking the feet of residents in warm water for a brief period of time before
washing the feet with a gentle soap is appropriate care.
2 Placing a gauze or commercial pad between toes that overlap each other is an
appropriate action to prevent skin breakdown in pressure areas.
3 The nurse needs to identify and question the suggestion to gently remove dry
skin from heels and callouses with a pumice stone. Many residents will be
older adults and the diagnosis of diabetes mellitus is common. A pumice stone
is used on the feet of a patient with diabetes only under the direction of a
podiatrist.
4 Massage and ROM performed on the feet and ankles are relaxing and
therapeutic. Alcohol-free lotion is used, but the lotion is not applied or allowed
to remain between the toes.
PTS: 1 CON: Tissue Integrity
6. A patient presents with skin lesions that appear reddened, with seeping areas partially
crusted over. The HCP orders a viral culture to be performed. Which action by the nurse is
inappropriate when collecting the culture specimen?
1. An intact vesicle is gently squeezed to obtain fluid.
2. A sterile cotton swab is used to acquire culture material.
3. The collected fluid is evenly distributed over a glass slide.
4. The specimen is immediately transported to the laboratory.
ANS: 3
Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic
Measures
Objective: Identify laboratory and diagnostic tests commonly performed to diagnose
integumentary disorders.
Page: 1152
Heading: Cultures
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Application (Applying)
Concept: Tissue Integrity
Difficulty: Moderate
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