Assessing The Integumentary System Chapter 15 Test Bank - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 15 Assessing the Integumentary System
1) A patient is experiencing a problem with the eccrine sweat glands. Which function should the nurse expect to be affected in this patient?
1. Regulation of body temperature
2. Regulation of body heat by excretion of perspiration
3. Sebum secretion
4. Sexual scent gland
Page Ref: 445
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
2) A patient reports avoiding the sun for fear of developing skin cancer. Which health problem is this patient at risk for developing?
1. Vitamin D deficiency
2. Hypercholesterolemia
3. Hypokalemia
4. Hypernatremia
Page Ref: 465
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
3) A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will heal and appear as it was prior to the burn. What knowledge of skin structures should the nurse use to respond to this patient? Select all that apply.
1. Most hair follicles are in the dermis.
2. Most sweat glands are in the dermis.
3. Hair follicles are in the subcutaneous tissue.
4. Sebaceous glands are in the dermis.
5. Receptors for pain and touch are in the dermis.
Page Ref: 454
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
4) The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. Which body area should be used as the best way to assess skin color changes in this patient?
1. Sclera
2. Palms of the hands
3. Fingernails
4. Skin of the inner arms
Page Ref: 455
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
5) An African American patient has an ashen cast to normally black skin. Which laboratory test results should the nurse review to determine a possible cause of the skin color change?
1. BUN and creatinine
2. Hemoglobin and hematocrit
3. Bilirubin and serum potassium
4. Oxygen saturation and red blood cell count
Page Ref: 455
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
6) A Caucasian patient is admitted with possible carbon monoxide poisoning. Which skin color should the nurse expect to support this medical diagnosis?
1. Bluish
2. Dusky red
3. Cherry red
4. Orange green
Page Ref: 455
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
7) While conducting a health history, the nurse learns that a patient worked at a steel mill for the last 35 years. Why should the nurse find this information significant?
1. Explains possible exposure to environmental toxins
2. Helps understand the patient's lack of communication skills
3. Validates that the patient is an older adult
4. Confirms the patient's level of education
Page Ref: 457
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
8) A patient seeks medical attention for an erythematous generalized rash. Which question should the nurse ask about the rash? Select all that apply.
1. "Have you recently eaten any new foods?"
2. "What medications do you take?"
3. "Have you changed your soap?"
4. "Have you changed skin care lotions?"
5. "How often do you walk outside?"
Page Ref: 456
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
9) A patient asks what caused an elevated, darkened area of excess scar tissue to develop. In which way should the nurse respond?
1. "This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow depression."
2. "This scar was caused by excessive collagen formation during healing."
3. "This scar was caused by skin loss extending into the dermis or subcutaneous tissue."
4. "This scar was caused by wasting of the skin due to loss of collagen."
Page Ref: 459
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
10) The nurse is performing an assessment of a patient's nails. What should be included in this examination? Select all that apply.
1. Thickness
2. Color
3. Curvature
4. Length
5. Grooves
Page Ref: 462-463
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
11) The nurse is providing care to patients in a community clinic. When should the nurse conduct a health assessment interview to determine problems with the integumentary system? Select all that apply.
1. When the patient has a complaint
2. As part of regular health screening
3. When completing a health assessment
4. Rarely, because it takes too much time
5. When the patient is over the age of 50
Page Ref: 456
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
12) A patient is diagnosed with oculocutaneous albinism. What does the nurse understand this health problem to be?
1. Hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin.
2. Disorder characterized by elevated scars and a familial tendency that is found more commonly in African Americans.
3. Sudden appearance of white patches on the skin, with a familial tendency.
4. Autosomal-dominant inheritance disorder that causes hyperpigmentation of the skin, hair, and eyes.
Page Ref: 457
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
13) A female patient who is concerned about excessive hair on her arms and legs states that other female family members have the same problem. How should the nurse respond?
1. "The excessive hair growth could be a result of your diet."
2. "Your hair growth patterns may be inherited."
3. "Your excessive hair growth could be caused by too much sun."
4. "Maybe you shave too much, which causes more hair growth."
Page Ref: 457
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
14) A patient complains of the sudden appearance of white patches on the skin. Which question should the nurse ask if vitiligo is suspected? Select all that apply.
1. "Have any of your parents or grandparents had this problem also?"
2. "Have you been using bleach lately?"
3. "Have you had anything rubbing on those areas excessively?"
4. "What have you been eating lately?"
5. "Where are the white patches located on your body?"
Page Ref: 457, 461
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
15) The nurse is completing an integumentary examination of an African American patient. Which finding should the nurse recognize is associated with the patient's genetics? Select all that apply.
1. An ashen hue to black skin
2. A yellowish cast on the palms
3. Very dry scalp and dry, fragile hair
4. Several keloids
5. Patches of white spots on the hands
Page Ref: 457
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
16) The nurse is caring for an older patient. What should the nurse keep in mind when caring for the patient's skin?
1. The subcutaneous layer grows thinner.
2. The epidermis thickens.
3. The number of Langerhans cells increases.
4. Sweat gland activity increases.
Page Ref: 465
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
17) The nurse is conducting a physical examination of the skin, hair, and nails. Why should the nurse note the age of the patient?
1. It alerts the nurse to expect age-related changes.
2. It validates that skin changes in the older population are pathologic.
3. It reminds the nurse that scaly, dry skin is more common in young adults.
4. It reinforces the concept that age is the most significant risk factor for cancer.
Page Ref: 464-465
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
18) The nurse is assessing the integumentary status of an older patient. What change should the nurse expect in this patient?
1. Decrease in abdominal fat
2. Increase in perfusion
3. Decrease in vitamin D production
4. Increase in vasomotor response
Page Ref: 465
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
19) During an integumentary assessment, an older patient is found to have a brown benign macule with a defined border. How should the nurse document this finding?
1. Keratosis
2. Angioma
3. Lentigine
4. Telangiectases
Page Ref: 464
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
20) A patient has an area of rough, thickened, hardened epidermis. What should the nurse suspect as the reason for this skin lesion?
1. Chronic dermatitis
2. Athlete's foot
3. Ear piercing
4. Psoriasis
Page Ref: 459
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
21) A patient has the following laboratory values: sodium 144 mEq/L; potassium 3.8 mEq/L; hemoglobin 8.4 g/dL; glucose 105 mg/dL. Which assessment finding might correlate with these values?
1. Nail plate is separate from the nail bed.
2. Nail folds are inflamed and swollen.
3. Nail is spoon-shaped.
4. Nail has a transverse groove.
Page Ref: 463
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
22) A patient with heart failure has 3+ lower extremity edema. Which description should the nurse use to most accurately document this patient's edema?
1. Slight pitting, no obvious distortion
2. Deeper pit, no obvious distortion
3. Pit is obvious, extremities are swollen
4. Pit remains with obvious distortion
Page Ref: 462
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
23) The nurse is caring for a patient with thinning of the nails. Which test result should the nurse use to aid in the diagnosis of this nail disorder?
1. Pulse oximetry
2. Hemoglobin
3. Serum albumin
4. White blood cell count
Page Ref: 463
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
24) The nurse documents that a patient has 4+ pitting edema on the lower right tibia. How many millimeters of depression occurred?
1. 2 mm
2. 4 mm
3. 6 mm
4. 8 mm
Page Ref: 462
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
25) A patient has a flat, nonpalpable change in the skin color on the back. Which characteristic should the nurse use to identify this skin color change as a macule?
1. Smaller than 1 cm, with a circumscribed border
2. Larger than 1 cm with an irregular border
3. Smaller than 0.5 cm
4. Group of lesions larger than 0.5 cm.
Page Ref: 458
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
26) A patient reports having a dark spot on the arm that is "getting bigger and occasionally bleeds." Which additional health information is most relative to this patient's symptoms? Select all that apply.
1. The patient's father had chronic obstructive pulmonary disease.
2. The patient plays golf three or four times a week.
3. The patient is male.
4. There is a history of cardiac disease in the patient's family.
5. The patient is a blue-eyed blonde.
Page Ref: 457
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
27) A patient is diagnosed with albinism. What finding should the nurse expect to assess in this patient?
1. Excessive body hair
2. White patches on the skin
3. Overgrowth of scar tissue
4. Very pale skin
Page Ref: 455, 457
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
28) An adolescent patient has extensive acne over the face and upper neck. Which factor should the nurse recognize as a reason for this health problem?
1. Inflamed sebaceous glands
2. Blocked endocrine glands
3. Blocked exocrine glands
4. Inflamed ceruminous glands
Page Ref: 455,458
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
29) A patient waiting to have a skin biopsy asks what occurs during the procedure. What should the nurse respond to this patient?
1. "Didn't your doctor tell you?"
2. "Maybe you shouldn't have it done."
3. "I'm not sure."
4. "Let me check to see exactly what you are having done and then we can talk more about what you can expect."
Page Ref: 463
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Therapeutic Communication
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7.Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
30) The nurse is preparing to assess a patient's integumentary status. Which technique should the nurse use to conduct this assessment?
1. Inspection
2. Inspection and percussion
3. Inspection and palpation
4. Percussion and palpation
Page Ref: 457
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
31) After completing an integumentary status assessment, the nurse documents "+1 edema right lower leg." What does this documentation indicate?
1. Slight pitting, no obvious distortion
2. Deep pitting, no obvious distortion
3. Pitting is obvious, extremities are swollen
4. Pitting remains with obvious distortion
Page Ref: 462
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
32) The nurse is assessing the integumentary status of an older patient. Which finding should the nurse considered expected in this patient? Select all that apply.
1. Keratoses
2. Skin tags
3. Urticaria
4. Photoaging
5. Acne
Page Ref: 464
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
33) The nurse is planning to assess an African American patient's integumentary status. Which finding indicates that this patient has cyanosis?
1. Yellow hue in the eyes
2. Bluish-tinged nail beds
3. Cherry-red lips
4. Orange-green cast to the skin
Page Ref: 455
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
34) A patient has the appearance of herpetic lesions found over the nose and mouth region. Which term should the nurse use to document this finding?
1. Scaly
2. Pustular
3. Pruritic
4. Ulcerated
Page Ref: 459, 461
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
35) During the assessment of an older patient's integumentary status, the nurse notes small areas of hyperpigmentation on the patient's hands. What should the nurse consider as the cause of this finding?
1. Hyperplasia of melanocytes in sun-exposed areas
2. Reduced vitamin D production
3. Decreased blood perfusion of the dermis
4. Redistribution of adipose tissue
Page Ref: 465
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
36) A patient is recovering from a biopsy that sampled a small section of dermis and subcutaneous fat. For which type of biopsy should the nurse plan care for this patient?
1. Incisional
2. Punch
3. Excisional
4. Shave
Page Ref: 463
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
37) A patient is scheduled for a test to diagnose for the presence of a herpes infection. For which diagnostic test should the nurse prepare the patient?
1. Patch test
2. Tzanck smear
3. Potassium chloride test
4. Wood's lamp examination
Page Ref: 464
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.
38) The nurse is preparing to assess a patient's integumentary status. What should the nurse do prior to beginning this examination? Select all that apply.
1. Obtain a gown and drape for the patient.
2. Cleanse the blood pressure cuff with alcohol.
3. Obtain several pairs of disposable gloves.
4. Ensure the examination room is warm and private.
5. Place a ruler and flashlight near the examination table.
Page Ref: 457
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.
39) The nurse is caring for an older patient with thin subcutaneous tissue. What action should the nurse take to ensure the patient's comfort and safety? Select all that apply.
1. Apply warm blankets.
2. Keep the room cool.
3. Use a lift sheet to reposition in bed.
4. Assess skin for areas of breakdown.
5. Encourage frequent position changes.
Page Ref: 465
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Basic Care and Comfort
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
40) During an integumentary assessment the nurse observes multiple areas of ecchymosis over the patient's arms, legs, and upper back. What problem should the nurse consider as a cause of these manifestations? Select all that apply.
1. Septicemia
2. Hemophilia
3. Liver disease
4. Vitamin C deficiency
5. Vitamin K deficiency
Page Ref: 460
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
41) The nurse suspects that a school-age child has ringworm of the scalp. What did the nurse assess to come to this conclusion? Select all that apply.
1. Coarse, dry hair
2. Areas of hair loss
3. Scaling on the scalp
4. Pustules on the scalp
5. Oval nits on the hair shaft
Page Ref: 462
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
42) Prior to assessing a patient's integumentary status, the nurse notes excessive perspiration. What should the nurse consider as a possible cause for this finding? Select all that apply.
1. The patient is hungry.
2. The patient is anxious.
3. The patient is in shock.
4. The patient has a fever.
5. The patient has been exercising.
Page Ref: 461
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system.
MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.
43) The nurse is preparing a brochure on sun safety for a community health fair. Which information should the nurse include? Select all that apply.
1. Limit the use of tanning booths.
2. Apply sunscreen when near sand, snow, concrete, or water.
3. Limit exposure to the sun between the hours of 10 am and 3 pm.
4. Apply sunscreen with an SPF of 15 or more every hour if sweating heavily.
5. Wear a wide-brimmed hat, long-sleeved shirt, and long pants when in the sun.
Page Ref: 465-466
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
44) The nurse is preparing to demonstrate the Slip! Slop! Slap! Wrap! method to prevent sun exposure. Which items should the nurse have available for the demonstration? Select all that apply.
1. Hat
2. Umbrella
3. Sunglasses
4. Long-sleeved shirt
5. Sunscreen of SPF 15 or higher
Page Ref: 466
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.
Document Information
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