Preview Extract
Chapter 65
1. When caring for a geriatric client, the nurse must remember that the following change
occurs as an individual ages:
1. Subcutaneous tissue decreases.
2. Both the epidermis and the dermis thicken.
3. The number of Merkel’s cells and Langerhans’ cells increases.
4. Sebaceous gland activity increases.
Answer: Subcutaneous tissue decreases
Rationale:
Sebaceous gland activity decreases, resulting in the older individual having drier and more
scaly skin. Both the epidermis and the dermis thin, making skin more susceptible to
breakdown. The subcutaneous tissue decreases, so the client has less padding, which also
makes the chance of skin breakdown greater. The number of Merkel’s cells and Langerhans’
cells decreases, which causes the older client to be more susceptible to infection.
2. During a conversation with the nurse, the client comments that he rarely goes outside when
the sun is shining because he is afraid of developing skin cancer. This would predispose the
client for developing:
1. Vitamin D deficiency.
2. Hypercholesterolemia.
3. Hypokalemia.
4. Hypernatremia.
Answer: Vitamin D deficiency.
Rationale:
The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol).
Hypercholesterolemia results from factors such as dietary intake and cholesterol that is
produced by the body. The skin does retard the loss of fluid and does play a role in fluid and
electrolyte balance. Exposure to sunlight does cause both decreased potassium (hypokalemia)
and increased sodium (hypernatremia).
3. An unconscious client whose identity is unknown is admitted to the emergency
department. The most important role the skin of the client plays in helping to identify the
client is to determine:
1. The race of the client.
2. The age of the client.
3. Any injuries the client may have sustained.
4. The sex of the client.
Answer: The race of the client.
Rationale:
The skin can help determine the identity of the patient; in addition to providing fingerprints,
the amount of melanin or carotene pigments in the skin provides information regarding race.
While changes in the skin that occur with aging may aid in estimating the age of the client, it
is only an estimate because there are other external factors that affect the appearance of the
skin. Determining the type of injuries sustained may be helpful in providing clues to the
person’s identity, but is not as significant as race in determining the identity. The skin does
not play a role in determining the sex of a client.
4. While taking a client’s health history, the nurse learns that the client worked at a landfill for
the last 35 years. This information is most significant because it could indicate:
1. Possible exposure to environmental toxins.
2. The client’s lack of communication skills.
3. The client is elderly.
4. The client’s level of education.
Answer: Possible exposure to environmental toxins.
Rationale:
While all of the client’s statements are important information to obtain when taking a health
history, the client’s occupation could involve exposure to such toxins as arsenic, coal tar,
creosote, and/or petroleum products. Landfills are a risk factor for skin cancer.
5. One of the first steps in an assessment is determining the “chief complaint.” The chief
complaint is:
1. The client’s current issue.
2. Determined after the nurse does a complete health history.
3. Formulated by the nurse.
4. A vague description of a problem.
Answer: The client’s current issue.
Rationale:
The chief complaint is the client’s current issue or reason for seeking health care. It is
generally a concise statement in the client’s own words. It is typically best elicited by the
nurse’s asking the client what he or she considers to be the most current and acute health
issue. The chief complaint is not determined by the nurse, nor is it a vague description of a
problem. The chief complaint is expressed by the client, not determined after a complete
health history.
6. It is most essential that the nurse use skillful interviewing techniques while completing a
health assessment of the skin, hair, and nails in order to:
1. Explore and investigate each symptom.
2. Gain the client’s trust.
3. Discard unimportant data.
4. Speed up the interview.
Answer: Explore and investigate each symptom.
Rationale:
Each symptom identified should be thoroughly described in order for the nurse to gain a full
understanding. The nurse may ask the client questions such as, “Tell me more about the
problem,” or “How did the problem start?” These types of questions will usually prompt the
client to proceed with further information about the symptoms. Skillful interviewing
techniques may gain the client’s trust, discard unimportant data, and speed up the interview,
but these are not as important as exploring and investigating symptoms.
7. A client is admitted to the unit with swelling of both lower extremities. During the physical
exam, the nurse palpates the client’s skin with the pads of her fingers and finds that the
indention formed is deep, but lasts only a short time. This finding indicates:
1. Pitting edema.
2. Loss of skin elasticity.
3. Decrease sensation.
4. Increased skin turgor.
Answer: Pitting edema.
Rationale:
If pressure leaves an indentation in the skin, pitting edema is present. Edema is caused by
accumulation of fluid in the intercellular spaces. Pitting edema is generally evaluated on a 4point scale. Loss of skin elasticity causes the skin to lack firmness, but the skin does indent
when palpated. A patient with edema does not have a decrease in sensation. Skin turgor is
assessed by pinching the skin to determine how quickly it returns to its normal shape.
8. When a nurse is conducting a physical examination of the skin, hair, and nails, the age of
the client is an important factor because:
1. There are age-related changes.
2. Skin changes in the older population are pathologic.
3. Scaly, dry skin is common in young adults.
4. It is the most significant risk factor for cancer.
Answer: There are age-related changes.
Rationale:
There are age-related changes. What is normal for a young person will be changed or absent
in the older population. Skin changes related to the aging process are not always pathologic.
The nurse must possess the knowledge of normal versus abnormal for each age group when
discussing the skin. Age is not the most significant risk factor for cancer. Scaly, dry skin is
not common in young adults.
9. When performing a physical examination of a client’s skin, the nurse should:
1. Be aware of ethnic differences.
2. Examine the least-exposed areas first.
3. Inspect the skin while the client is standing up.
4. Examine only the areas of specific concern.
Answer: Be aware of ethnic differences.
Rationale:
Ethnic differences are important because of the difference in skin color. For example, in darkskinned people the best areas to assess pallor, cyanosis, and jaundice are the oral mucous
membranes and conjunctiva. The nurse should inspect the skin while the client is in a sitting
or lying position and should begin by examining the most frequently exposed area first. A
brief but careful look at the client’s body should be done, and then areas of specific concern
should be examined in detail.
10. During a physical exam of the client’s nails, the nurse depresses the nail edge to blanch
and then releases it. This technique will allow the nurse to assess:
1. Capillary refill.
2. The client’s nail bed.
3. How brittle the client’s nails are.
4. If clubbing of the nail is present.
Answer: Capillary refill.
Rationale:
The nail plate is translucent. To determine capillary refill, the nail edge is depressed to blanch
and is released, noting the return of color. Capillary refill is usually documented as brisk,
which is a normal response. Depressing the nail edge would have no effect on the nail bed.
Brittle nails are diagnosed by looking at the distal plates of the nail to inspect for splitting and
peeling of the nail. Clubbing is assessed by looking at the angle of the nail bed.
11. Using correct technique for assessing a client’s skin turgor, the nurse would:
1. Grasp a fold of the patient’s skin using the forefinger and thumb.
2. Palpate the skin.
3. Blanch the nail bed.
4. Determine the client’s fluid intake for past 2 hours.
Answer: Grasp a fold of the patient’s skin using the forefinger and thumb.
Rationale:
Turgor refers to the elasticity and mobility of the skin. Elasticity is the skin’s ability to return
to a normal position and shape, and mobility is the skin’s ability to be lifted. To assess turgor,
the nurse would grasp a fold of the patient’s skin using the forefinger and thumb. The nurse
notes how rapidly the skin returns to its normal shape. Elasticity and mobility of the skin
cannot be determined by palpating the skin. Blanching the nail bed assesses capillary refill,
which indicates circulation in the extremity. Turgor is an indication of hydration, but will not
indicate when or how much fluid has been taken.
12. The nurse must palpate the skin to assess the texture of the client’s skin. The correct
technique is to use the:
1. Palmer surface of the fingers and finger pads.
2. Dorsal surface of the hand.
3. Anterior surface of the wrist.
4. Palm of the hand.
Answer: Palmer surface of the fingers and finger pads.
Rationale:
Palpation is the examination of the skin through the use of touch. The palmer surface of the
fingers and finger pads should be used to assess the texture. Use of the palm or dorsal surface
of the hand, or the anterior surface of the wrist, would not demonstrate correct technique.
13. While performing the assessment for bilateral symmetrical skin temperature, the nurse
finds that the client’s left hand skin temperature is much cooler that the skin temperature of
the right hand. This finding could indicate:
1. Peripheral arterial insufficiency.
2. Hypothyroidism.
3. Infection.
4. Overuse.
Answer: Peripheral arterial insufficiency.
Rationale:
Peripheral arterial insufficiency decreases the blood flow to the area, which results in
decreased local skin temperature. Hypothyroidism would cause a generalized decrease in skin
temperature. An infection could cause an increase in localized skin temperature. Overuse is
not likely to cause a difference in temperature.
14. A client is admitted with edematous lower extremities. The nurse palpates the client’s skin
and finds that when pressure is applied, a deep indentation occurs and lasts for a short time.
Based on a 4-point scale, this finding would be documented as:
1. 3+ pitting edema.
2. 1+ pitting edema.
3. 2+ pitting edema.
4. 4+ pitting edema.
Answer: 3+ pitting edema.
Rationale:
On a 4-point scale, 3+ pitting edema describes deep pitting with the indentation lasting a
short time. 1+ pitting edema describes mild pitting in which there is slight indentation and no
obvious swelling. 2+ pitting edema indicates moderate pitting in which the indentation
rapidly subsides. 4+ pitting edema describes very deep pitting in which the indentation lasts a
long time.
15. A client is very concerned about a vesicle on the lip that extends onto the skin. The
patient’s history reveals this vesicle has been present for 3 days. After assessing the vesicle,
the nurse concludes that the vesicle is probably:
1. A herpes infection.
2. Skin cancer.
3. Due to systemic dehydration.
4. Due to a recent injury.
Answer: A herpes infection
Rationale:
Herpes is a viral infection that presents with a vesicle on the lip that extends onto the skin.
Skin cancer most commonly occurs on the lower lip or underside of the tongue and is
suspected when there is an open area that does not heal. Systemic dehydration may be
manifested in dry, scaling, cracking lips. A lesion from a recent injury would vary depending
on the exact injury, and a history of the injury would be determined during the history.
16. The nurse discovers a vascular lesion on a client’s chest. To help the nurse determine if
the lesion is pectechie or telangiectasia, the nurse should check if the lesion:
1. Will blanch.
2. Is raised.
3. Is scaly.
4. Is painful.
Answer: Will blanch.
Rationale:
Determining whether a lesion will blanch will help identify the type of lesion. Pectechie will
not blanch, whereas telangiaectases will blanch. Neither pectechie nor telangiectasia is raised,
scaly, or painful.
17. A client with a history of chronic allergic dermatitis is concerned because of area where
the skin had become thickened and rough. This type of lesion is:
1. Lichenification.
2. Excoriation.
3. Ulceration.
4. Ecchymosis.
Answer: Lichenification.
Rationale:
Conditions such as chronic dermatitis can cause the epidermis to become rough and
thickened. Superficial skin markings will also become more visible. Excoriation is an
abrasion of the epidermis. Ulceration is a localized area of tissue necrosis. Ecchymosis is a
red-purple discoloration of the skin.
18. A 50-year-old client is concerned because several firm, deep-red papules have appeared
on both legs and the number is increasing. The nurse recognizes these lesions as:
1. Cherry angiomas.
2. Purpura.
3. Venous stars.
4. Spider angiomas.
Answer: Cherry angiomas.
Rationale:
A cherry angioma is a firm, deep-red papule and is a benign vascular lesion. It is generally
found on most people after age 30, and the incidence increases with age. Purpura is a redpurple lesion that is greater than 0.5 centimeter in diameter and is caused by intravascular
defects or infection. A venous star is a bluish irregular spider shape with linear lines and is
caused by increased pressure in superficial veins. A spider angioma has a red central body
with radiating spider-like legs and can be caused by liver disease or vitamin B deficiency.
19. The nurse notes a yellowish discoloration of the client’s skin, but it does not involve the
sclera or mucous membranes. The nurse should question the client about:
1. Dietary intake.
2. History of hepatitis.
3. Ethnicity.
4. Food allergies.
Answer: Dietary intake.
Rationale:
The yellowish discoloration of the client’s skin could be carotenemia. It is often associated
with a high intake of foods with carotene (sweet potatoes, squash, and carrots). Jaundice
associated with liver involvement will usually involve the sclera of the eyes. Asians have a
higher level of carotene in their skin, which causes a yellow hue to the skin, but it does not
cause a yellowish discoloration. Food allergies do not cause discoloration of the skin, but will
usually cause a reaction such as a rash or urticaria.
20. While palpating the nail bed of an African American client, the nurse notes that the
client’s nails have linear bands along the nail edge. This finding:
1. Is found in dark-skinned individuals.
2. Indicates a fungal infection of the nail bed.
3. Indicates a nutritional deficiency.
4. Indicates the client is cyanotic.
Answer: Is found in dark-skinned individuals
Rationale:
The nail plate is translucent and the nurse should expect to see a pink nail bed. Dark-skinned
individuals may have brownish pigmented areas or linear bands along the nail edge. A fungal
infection of the nail usually causes deformed, cracked nails that turn yellow or brown. A
vitamin deficiency may cause nails to have pits, transverse grooves, or lines. The nail beds of
a client who is cyanotic will have a bluish hue. The nail beds of dark-skinned clients may
appear have an ashen-gray hue.
21. A client from Southeast Asia who has been ill with influenza is admitted with selfinflicted open sores and bruising on both forearms. When questioned about the wounds, the
client stated that it was done to aid in the healing process. The nurse should recognize:
1. This may be a cultural practice.
2. The client is delusional.
3. The client belongs to a cult.
4. The cause of the wounds is unimportant.
Answer: This may be a cultural practice.
Rationale:
It is important to determine the cause of the wounds. This client’s actions may indicate a
cultural practice. It is important for the nurse to inquire about any cultural habits or practices
that may affect the patient’s skin. This is an opportunity for the nurse to educate the client
regarding safe health practices while being nonjudgmental. A client who performs a cultural
health practice is not delusional; it is part of the culture. Cultural practices are not related to a
client being a member of a cult.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
