MULTIPLE CHOICE

1. The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms. What is the client’s priority problem?

a.            Risk for injury

b.            Infection

c.             Poor self-image

d.            Discomfort

ANS: A

Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk for injury in response to even minimal trauma or shearing events. If injury occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take priority over the risk for injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Planning)

2. A client has a suspected superficial fungal infection. The nurse prepares the client for a culture by explaining the procedure. Which statement by the client indicates a correct understanding of the procedure?

a.            “The doctor will shave off a small piece of the lesion.”

b.            “You will be performing what is called a punch biopsy.”

c.             “A sample is obtained by simply scraping the lesion.”

d.            “You’ll squeeze material from the lesion to send to the laboratory.”

ANS: C

A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade. The other techniques are not used for a suspected superficial fungal infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation, what is the nurse’s best action?

a.            Evaluate the client further for hepatitis.

b.            Examine the soles of the client’s feet.

c.             Inspect the client’s oral mucosa.

d.            Place the client in contact isolation.

ANS: C

The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits that show a yellow hue. Before considering hepatitis, the nurse must do a more thorough assessment. The soles of the feet may appear yellow simply from calluses, so this is not the best place to assess. No need to isolate the client has been identified.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data, what does the nurse do next?

a.            Take a medication history.

b.            Assess pulse oximetry.

c.             Assess the client’s personal hygiene.

d.            Palpate the soles and palms.

ANS: B

Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and conjunctivae have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

5. An older client with age spots is fearful of contracting skin cancer but wants to continue his hobby of outdoor gardening. Which statement by the client indicates a good understanding of the teaching about this issue?

a.            “I will avoid staying outside during the day.”

b.            “I can use only oil-based tanning lotion.”

c.             “I have to start growing plants indoors.”

d.            “I will wear a hat and gloves when gardening.”

ANS: D

Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin protects against the harmful effects of sun exposure. Hyperpigmentation can occur in sun-exposed areas and can lead to skin cancer. For clients who spend time outdoors, the best protection from skin cancer is decreasing the amount of skin exposed to sunlight.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

6. An older client expresses concern about developing new “age spots.” Which instruction is most important for the nurse to provide to the client?

a.            “Limit the time you spend in the sun.”

b.            “Monitor for signs of infection.”

c.             “Monitor spots for color change.”

d.            “Use skin creams to prevent drying.”

ANS: C

The ABCDE method (check for asymmetry, border irregularity, color variation, diameter, and evolving [changing] in any feature) should be used to assess lesions for signs associated with cancer. Any positive finding using this method requires the lesion to be examined by a dermatologist or a surgeon. The other options are good instructions for clients too, but this client is worried about lesions that are already present.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

7. A client is seen in the clinic for a persistent hand rash. When taking the client’s history, the nurse places priority on obtaining information related to which topic?

a.            Age

b.            Gender

c.             Occupation and hobbies

d.            Socioeconomic status

ANS: C

The location of the rash suggests contact dermatitis. This condition is most often caused by contact with irritating substances such as might be found in industrial settings or associated with specific hobbies. Socioeconomic status may be related to the rash, particularly if it is associated with poor hygiene, but age and gender are not related to rashes.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)