10 Questions for

Integumentary
Submitted by: Pauline R. Basi
1. Nurse May is caring for an elderly bedridden adult. To prevent
pressure ulcers, which intervention should the nurse include in the plan
of care?

a. Turn and reposition the client at least once every 8 hours.

b. Vigorously massage lotion into bony prominences.
c. Post a turning schedule at the client’s bedside.
d. Slide the client, rather than lifting, when turning.

Answer: C
 A turning schedule with a signing sheet
will help ensure that the client gets turned
and, thus, help prevent pressure ulcers.
Turning should occur every 1 to 2 hours —
not every 8 hours — for clients who are in
bed for prolonged periods. The nurse
should apply lotion to keep the skin moist
but should avoid vigorous massage, which
could damage capillaries. When moving
Rationale the client, the nurse should lift — rather
than slide — the client to avoid shearing.
2. Nurse Jane formulates a nursing diagnosis of Impaired physical
mobility for a client with third-degree burns on the lower portions of
both legs. To complete the nursing diagnosis statement, the nurse
should add which “related-to” phrase?

a. Related to fat emboli

b. Related to infection
c. Related to femoral artery occlusion
d. Related to circumferential eschar

 Answer: D
 As edema develops on circumferential
burns, eschar forms a tight, constricting
band, compromising circulation to the
extremity distal to the circumferential
site and impairing physical mobility. This
client isn’t likely to develop fat emboli
unless long bone or pelvic fractures are
present. Infection doesn’t alter physical
Rationale mobility. A client with burns on the lower
portions of both legs isn’t likely to have
femoral artery occlusion.
3. The nurse is assessing for the presence of cyanosis in a
male dark-skinned client. The nurse understands that which
body area would provide the best assessment?

a. Lips
b. Sacrum
c. Earlobes
d. Back of the hands

Answer: A
 In a dark-skinned client, the nurse
examines the lips, tongue, nail beds,
conjunctivae, and palms of the hands
and soles of the feet at regular intervals
for subtle color changes. In a client with
cyanosis, the lips and tongue are gray;
the palms, soles, conjunctivae, and nail
beds have a bluish tinge.
Rationale
4. Which of the following individuals is least likely to be at
risk of developing psoriasis?

a. A 32 year-old-African American
b. A woman experiencing menopause
c. A client with a family history of the disorder
d. An individual who has experienced a significant amount of emotional distress

 Answer: A
 Psoriasis occurs equally among women
and men, although the incidence is
lower in darker skinned races and
ethnic groups. A genetic predisposition
has been recognized in some cases.
Emotional distress, trauma, systemic
illness, seasonal changes, and
Rationale hormonal changes are linked to
exacerbations.
5. Which of the following clients would least likely be at
risk of developing skin breakdown?

a.  A client incontinent of urine feces

b. A client with chronic nutritional deficiencies
c. A client with decreased sensory perception
d. A client who is unable to move about and is confined to bed

Answer: C
 Bed or chair confinement, inability to
move, loss of bowel or bladder control,
poor nutrition, absent or inconsistent
caregiving, and decreased sensory
perception can contribute to the
development of skin breakdown. The
least likely risk, as presented in the
options, is the decreased sensory
perception. Options A, B, and D identify
Rationale physiological conditions, which are the
risk priorities.
6. The nurse is assigned to care for a female client with herpes zoster
(Shingles). Which of the following characteristics would the nurse
expect to note when assessing the lesions of this infection?

a. Clustered skin vesicles

b. A generalized body rash
c. Small blue-white spots with a red base
d. A fiery red, edematous rash on the cheeks

Answer: A
 The primary lesion of herpes zoster is a
vesicle. The classic presentation is
grouped vesicles on an erythematous
base along a dermatome. Because the
lesions follow nerve pathways, they do
not cross the midline of the body.
Options B, C, and D are incorrect
descriptions of herpes zoster.
Rationale
7. When assessing a lesion diagnosed as malignant
melanoma, the nurse in-charge most likely expects to note
which of the following?

a. An irregular shaped lesion

b. A small papule with a dry, rough scale
c. A firm, nodular lesion topped with crust
d. A pearly papule with a central crater and a waxy border

Answer: A
 A melanoma is an irregularly shaped
pigmented papule or plaque with a
red-, white-, or blue-toned color. Basal
cell carcinoma appears as a pearly
papule with a central crater and rolled
waxy border. Squamous cell carcinoma
is a firm, nodular lesion topped with a
Rationale crust or a central area of ulceration.
Actinic keratosis, a premalignant
lesion, appears as a small macule or
papule with a dry, rough, adherent
8. The nurse prepares discharge instructions for a male client following
cryosurgery for the treatment of a malignant skin lesion. Which of the
following should the nurse include in the instruction?

a. Avoid showering for 7 to 10 days

b. Apply ice to the site to prevent discomfort
c. Apply alcohol-soaked dressing twice a day
d. Clean the site with hydrogen peroxide to prevent infection

Answer: D
 Cryosurgery involves the local application of
liquid nitrogen to isolated lesions and causes
cell death and tissue destruction. The nurse
informs the client that swelling and increased
tenderness of the treated area can occur when
the skin thaws. Tissue freezing is followed by
hemorrhagic blister formation in 1 to 2 days.
The nurse instructs the client to clean the
treatment site with hydrogen peroxide to
prevent secondary infection. A topical
antibiotic also may be prescribed. Application
Rationale of a warm, damp washcloth intermittently to
the site will provide relief from any discomfort.
Alcohol-soaked dressings will cause irritation.
The client does not need to avoid showering.
9. The evening nurse reviews the nursing documentation in the male
client’s chart and notes that the day nurse has documented that the
client has a stage II pressure ulcer in the sacral area. Which of the
following would the nurse expect to note on assessment of the client’s
sacral area?

a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis

Answer: D
  In a stage II pressure ulcer, the skin is
not intact. Partial-thickness skin loss of
the dermis has occurred. It presents as
a shallow open ulcer with a red-pink
wound bed, without slough. It may
also present as an intact, open or
ruptured, serum-filled blister. The skin
Rationale is intact in stage I. Full-thickness skin
loss occurs in stage 3. Exposed bone,
tendon, or muscle is present in stage
4.
10. The nurse is teaching a female client with a leg ulcer about tissue
repair and wound healing. Which of the following statements by the
client indicates effective teaching?

a. “I’ll limit my intake of protein.”

b. “I’ll make sure that the bandage is wrapped tightly.”
c. “My foot should feel cold.”
d.  “I’ll eat plenty of fruits and vegetables.”

Answer: D
  For effective tissue healing, adequate
intake of protein, vitamin A, B complex, C,
D, E, and K are needed. Therefore, the
client should eat a high protein diet with
plenty of fruits and vegetables to provide
these nutrients. The bandage should be
secure but not too tight to impede
Rationale circulation to the area (needed for tissue
repair). If the client’s foot feels cold,
circulation is impaired, thus inhibiting
wound healing.