Skin Additional Questions PDF

1. Application-Based Multiple Choice Question A nurse is assessing an older adult patient and notices thinning of the skin, dryness, and diminished hair. Which of the following actions is most appropriate to prevent skin breakdown in this patient? A. Recommend the use of a tanning bed for v...

1. Application-Based Multiple Choice Question A nurse is assessing an older adult patient and notices thinning of the skin, dryness, and diminished hair. Which of the following actions is most appropriate to prevent skin breakdown in this patient? A. Recommend the use of a tanning bed for vitamin D synthesis. B. Encourage frequent hand washing with antibacterial soap. C. Advise the patient to use sunscreen and protective clothing. D. Suggest the use of hot water for bathing to improve circulation. Answer: C. Advise the patient to use sunscreen and protective clothing. Rationale: Older adults are at increased risk for skin breakdown due to thinning skin and decreased elasticity. Protecting the skin from UV damage, which can accelerate breakdown, is essential. Tanning beds increase the risk of skin damage, while hot water can dry out the skin, worsening the condition. 2. Select All That Apply (Critical Thinking) A nurse is educating a patient with diabetes about skin care. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. “Check your skin daily for any signs of redness or breakdown.” B. “Moisturize your skin after bathing to maintain hydration.” C. “Avoid trimming your nails to prevent accidental cuts.” D. “Wear loose, breathable clothing to reduce moisture buildup.” E. “Use a heating pad to improve circulation in your feet.” Answer: A, B, and D Rationale: Patients with diabetes should inspect their skin daily, especially on their feet, for any signs of breakdown, as they are prone to delayed healing. Moisturizing after bathing helps maintain skin hydration, and loose clothing prevents moisture buildup, which could lead to skin infections. Trimming nails is safe with proper techniques, and heating pads should be avoided as they can cause burns in patients with reduced sensation. 3. Application-Based Multiple Choice Question A teenager is concerned about acne and has been using multiple skincare products. During the assessment, the nurse should prioritize asking about: A. The amount of sleep the teenager gets each night.  B. The types of skincare and cosmetic products used. C. The teenager’s diet, particularly sugar and dairy intake. D. The teenager’s level of physical activity. Answer: B. The types of skincare and cosmetic products used. Rationale: Many skincare products can irritate the skin or worsen acne if used improperly or excessively. It’s essential to assess the products used to identify potential irritants. Although diet and sleep can impact skin health, the immediate priority is understanding the skincare regimen. 4. Critical Thinking Multiple Choice Question A patient with poor circulation is at increased risk for skin breakdown. Which of the following statements best explains why poor circulation leads to skin breakdown? A. Poor circulation reduces the skin’s temperature, which makes it more vulnerable to injury. B. Reduced blood flow limits the skin’s access to oxygen and nutrients, impairing healing. C. Lack of circulation increases the amount of sweat, leading to skin breakdown. D. Poor circulation causes the skin to dry out, leading to immediate skin breakdown. Answer: B. Reduced blood flow limits the skin’s access to oxygen and nutrients, impairing healing. Rationale: Good circulation is necessary to deliver oxygen and nutrients to the skin, which promotes healing and resilience. Without sufficient blood flow, the skin becomes less able to repair itself, making it more susceptible to injury and infection. 5. Select All That Apply (Application) A nurse is teaching a group of caregivers about preventing pressure injuries. Which interventions should the nurse include? (Select all that apply.) A. Reposition patients every two hours. B. Use pillows or foam pads to reduce pressure on bony areas. C. Limit the use of lotion on the skin to reduce moisture. D. Encourage patients to drink water regularly. E. Instruct patients to spend most of the day lying on their backs. Answer: A, B, and D Rationale: Repositioning helps distribute pressure, and pillows or foam pads reduce pressure on bony prominences, lowering the risk of pressure injuries. Hydration is essential for skin health, making it less likely to crack and break down. Limiting lotion use and having patients lie in one position are incorrect as they do not support skin integrity. Integumentary System Basics 1. A nurse is assessing a patient’s skin. Which of the following findings is most concerning and should be reported to the healthcare provider? ○ A. Dry, flaky skin on the arms ○ B. Small bruises on the legs ○ C. Yellowish discoloration of the skin and sclera ○ D. Slight redness after a bandage is removed 2. Answer: C. Yellowish discoloration of the skin and sclera. Rationale: Yellowing of the skin and sclera, or jaundice, can indicate liver dysfunction and should be reported. The other findings may be less concerning but still warrant documentation. 2. What is the primary function of the skin that helps prevent infection? ○ A. Sensation ○ B. Fluid balance ○ C. Temperature regulation ○ D. Protection 3. Answer: D. Protection. Rationale: The skin’s primary role in preventing infection is protection, serving as a barrier against pathogens. 3. Select All That Apply: Which of the following functions are performed by the skin? (Select all that apply.) ○ A. Temperature regulation ○ B. Oxygenation ○ C. Sensation ○ D. Nutrient production ○ E. Fluid balance 4. Answer: A, C, and E Rationale: The skin is involved in temperature regulation, sensation, and fluid balance. Oxygenation is a function of the respiratory system, and nutrient production is mainly a function of the digestive system. 4. A nurse is teaching a patient about hydration and its effects on skin health. Which of the following statements indicates the patient understands the teaching? ○ A. “If I drink more water, my skin will get enough blood flow.”  ○ B. “Staying hydrated helps my skin heal faster.” ○ C. “Drinking water will prevent all types of skin breakdown.” ○ D. “Hydration affects only the outer layer of my skin.” 5. Answer: B. “Staying hydrated helps my skin heal faster.” Rationale: Hydration aids in skin healing and helps maintain skin integrity, although it doesn’t prevent all types of skin breakdown or directly impact blood flow. Peripheral Vascular System 5. A patient presents with swollen lymph nodes. Which additional assessment finding should the nurse prioritize in evaluating the lymphatic system? ○ A. Skin dryness ○ B. Lymph node size and consistency ○ C. Nail configuration ○ D. Capillary refill time 6. Answer: B. Lymph node size and consistency. Rationale: When assessing swollen lymph nodes, it’s crucial to evaluate their size, consistency, and tenderness, as these can indicate infection or other issues. 6. Which of the following patients is at highest risk for compromised peripheral vascular health? ○ A. A teenager with acne ○ B. A middle-aged smoker ○ C. A patient with a low-protein diet ○ D. A child with a history of ear infections 7. Answer: B. A middle-aged smoker. Rationale: Smoking is a significant risk factor for peripheral vascular diseases because it impairs blood flow and circulation. 7. Select All That Apply: Which of the following are expected findings in a peripheral vascular assessment? (Select all that apply.) ○ A. Capillary refill under 2 seconds ○ B. Distal pulses +2 bilaterally ○ C. Presence of cyanosis ○ D. Edema in both feet ○ E. No palpable lymph nodes in the neck 8. Answer: A, B, and E Rationale: Normal peripheral vascular findings include quick capillary refill, palpable distal pulses, and no abnormal lymph nodes. Pressure Injury Prevention 8. A nurse is using the Braden Scale to assess a patient’s risk for pressure injuries. Which of the following factors does the Braden Scale evaluate? ○ A. Mobility, sensory perception, and moisture ○ B. Age, body mass index, and diet ○ C. Pain tolerance, hydration, and temperature ○ D. Medication use, history of allergies, and smoking 9. Answer: A. Mobility, sensory perception, and moisture. Rationale: The Braden Scale assesses risk factors like mobility, sensory perception, and exposure to moisture to predict pressure injury risk. 9. Which patient is most at risk for developing a pressure injury? ○ A. A teenager with a fractured leg in a cast ○ B. An older adult who is bedridden and incontinent ○ C. A middle-aged adult who spends long hours at a desk job ○ D. A child recovering from a mild infection 10. Answer: B. An older adult who is bedridden and incontinent. Rationale: Being bedridden and incontinent increases the risk for skin breakdown due to constant pressure and moisture exposure. 10. Select All That Apply: Which of the following interventions can help prevent pressure injuries? (Select all that apply.) ○ A. Use pillows under bony areas ○ B. Encourage daily sun exposure ○ C. Reposition the patient every two hours ○ D. Massage the skin over pressure points ○ E. Ensure the patient is well-hydrated 11. Answer: A, C, and E Rationale: Positioning, hydration, and padding help prevent pressure injuries. Sun exposure and massage over bony areas can cause further skin damage. Lifespan Considerations 11. A nurse is assessing an adolescent patient. Which of the following skin changes is most commonly associated with this age group? ○ A. Thinning of the skin  ○ B. Wrinkling and sagging ○ C. Stretch marks and acne ○ D. Decreased skin elasticity 12. Answer: C. Stretch marks and acne. Rationale: Adolescents often experience rapid growth, leading to stretch marks, and increased oil production, leading to acne. 12. Which of the following is a common skin change in older adults? ○ A. Increased moisture ○ B. Increased elasticity ○ C. Thinning of the skin ○ D. Rapid healing of skin injuries 13. Answer: C. Thinning of the skin. Rationale: Aging often leads to thinner, more fragile skin with decreased elasticity and slower healing. Critical Thinking Scenarios 13. A nurse is assessing a patient with a history of diabetes. Which assessment finding is most concerning for potential skin complications? ○ A. Smooth, soft skin ○ B. Small areas of redness on the feet ○ C. Increased hair growth on the legs ○ D. Intact skin on the lower extremities 14. Answer: B. Small areas of redness on the feet. Rationale: Redness can indicate early signs of skin breakdown or pressure, particularly concerning in diabetic patients with reduced sensation. 14. A patient presents with an erythematous (red) area on the skin after prolonged pressure. What is the first action the nurse should take? ○ A. Apply lotion to the area ○ B. Elevate the affected limb ○ C. Reposition the patient and document the findings ○ D. Apply a warm compress 15. Answer: C. Reposition the patient and document the findings. Rationale: Repositioning is essential to relieve pressure, and documentation ensures that the area is monitored for worsening. Health Promotion Practices 15. Select All That Apply: Which health promotion practices can help maintain skin integrity? (Select all that apply.) ○ A. Daily moisturizing ○ B. Use of tanning beds for vitamin D ○ C. Use of sunscreen during outdoor activities ○ D. Avoiding smoking ○ E. Applying lotions to minor cuts for quick healing 16. Answer: A, C, and D Rationale: Moisturizing, sunscreen, and avoiding smoking support skin integrity, while tanning beds and lotions on cuts are not recommended practices. 16. A nurse is teaching a patient about preventing skin dryness. Which of the following instructions is most appropriate? ○ A. “Use hot water when bathing to open your pores.” ○ B. “Limit showering to avoid washing away natural oils.” ○ C. “Apply a light layer of lotion only once a week.” ○ D. “Dry your skin completely and avoid any moisturizers.” 4o You said: that is not 20 ChatGPT said: ChatGPT You're right! I'll complete the set with the remaining questions to reach a total of 20. Continued: Health Promotion Practices 16. A nurse is teaching a patient about preventing skin dryness. Which of the following instructions is most appropriate? ○ A. “Use hot water when bathing to open your pores.” ○ B. “Limit showering to avoid washing away natural oils.” ○ C. “Apply a light layer of lotion only once a week.” ○ D. “Use lukewarm water and apply moisturizer immediately after bathing.” 17. Answer: D. “Use lukewarm water and apply moisturizer immediately after bathing.” Rationale: Using lukewarm water and moisturizing right after bathing helps lock in moisture, which is important for preventing dryness. Integumentary and Peripheral Vascular Systems 17. A nurse is conducting a health history for a patient with poor skin health. Which of the following factors is most likely to contribute to this patient’s skin issues? ○ A. History of smoking ○ B. Use of skin moisturizer daily ○ C. Regular physical activity ○ D. Low intake of caffeine 18. Answer: A. History of smoking. Rationale: Smoking is a major risk factor that impairs blood flow and skin health, leading to compromised skin integrity. 18. Select All That Apply: Which of the following are appropriate assessment points for evaluating skin integrity in older adults? (Select all that apply.) ○ A. Skin elasticity ○ B. Presence of lesions or discoloration ○ C. Hair distribution ○ D. Nail color and shape ○ E. Skin thickness 19. Answer: A, B, and E Rationale: Skin elasticity, presence of lesions, and skin thickness are essential aspects of assessing skin integrity, especially in older adults where these factors change with age. 19. A nurse is educating a patient on the importance of peripheral circulation for skin health. Which statement by the patient indicates correct understanding? ○ A. “As long as I drink water, my skin will heal quickly.” ○ B. “Good circulation helps deliver oxygen and nutrients to my skin.” ○ C. “Taking extra vitamin C will prevent any circulation issues.” ○ D. “Eating fatty foods is necessary for proper skin blood flow.” 20. Answer: B. “Good circulation helps deliver oxygen and nutrients to my skin.” Rationale: Adequate circulation is critical for delivering nutrients and oxygen, which are essential for maintaining skin health and healing. 20. Critical Thinking Multiple Choice Question: A nurse observes a patient with a history of diabetes has dry, cracked skin on their feet. What is the most appropriate intervention? ○ A. Suggest they apply lotion between the toes ○ B. Advise them to soak their feet daily in warm water  ○ C. Recommend they avoid moisturizing their feet to prevent fungal growth ○ D. Encourage use of lotion on the feet, avoiding areas between the toes 21. Answer: D. Encourage use of lotion on the feet, avoiding areas between the toes. Rationale: Diabetic patients should moisturize their feet to prevent dryness but avoid the area between the toes to reduce the risk of fungal infections. Lifespan Considerations 21. A nurse is assessing skin elasticity in an elderly patient. Which assessment finding is typical for this age group? ○ A. Skin with good turgor ○ B. Thick and oily skin ○ C. Skin that tents when pinched ○ D. Redness and warmth throughout 22. Answer: C. Skin that tents when pinched. Rationale: Tenting is common in older adults due to decreased elasticity and hydration, a normal part of aging. 22. A patient asks why older adults are more prone to bruising. The nurse’s best response is: ○ A. “Older adults have increased blood flow, which causes bruising.” ○ B. “Aging causes the skin to lose fat and elasticity, making it more fragile.” ○ C. “Older adults have fewer white blood cells to protect against bruising.” ○ D. “Increased collagen makes the skin weaker.” 23. Answer: B. “Aging causes the skin to lose fat and elasticity, making it more fragile.” Rationale: Aging skin becomes thinner and loses fat, making it more susceptible to bruising and injury. 23. A teenage patient is self-conscious about acne. Which intervention should the nurse prioritize? ○ A. Suggest using multiple skin products to address acne. ○ B. Educate on using gentle cleansers and avoiding harsh chemicals. ○ C. Recommend wearing makeup to cover acne. ○ D. Advise reducing water intake to prevent skin oiliness. 24. Answer: B. Educate on using gentle cleansers and avoiding harsh chemicals. Rationale: Gentle skincare and avoiding irritants are key to managing acne in teenagers without causing further skin damage. Preventing Skin Breakdown  24. A nurse is caring for a bedbound patient. Which intervention is most effective in preventing pressure injuries? ○ A. Limiting fluid intake to prevent incontinence ○ B. Using a sheet under the patient to avoid direct contact with the mattress ○ C. Repositioning the patient at least every two hours ○ D. Allowing the patient to remain in one position if comfortable 25. Answer: C. Repositioning the patient at least every two hours. Rationale: Frequent repositioning is essential to redistribute pressure and prevent tissue ischemia, reducing the risk of pressure injuries. 25. Select All That Apply: Which of the following lifestyle changes can improve skin health? (Select all that apply.) ○ A. Drinking more water ○ B. Smoking cessation ○ C. Using tanning beds for short durations ○ D. Increasing fruit and vegetable intake ○ E. Exercising regularly 26. Answer: A, B, D, and E Rationale: Hydration, quitting smoking, balanced nutrition, and exercise all support skin health, while tanning beds are harmful. 1. A nurse is assessing a patient at risk for pressure injuries. Which of the following findings indicates the patient has a Stage 2 pressure injury? A. Intact skin with non-blanchable redness. B. A blister with a pink or red wound bed. C. Full-thickness skin loss with visible fat tissue. D. Full-thickness tissue loss with exposed bone or muscle. Answer: B. A blister with a pink or red wound bed. Rationale: Stage 2 pressure injuries include partial-thickness skin loss with exposed dermis, commonly appearing as a pink or red wound bed or a serum-filled blister. 2. The nurse is using the Braden Scale to assess a patient's risk for pressure injuries. Which of the following Braden Scale scores indicates that a patient is at high risk? A. 20 B. 16 C. 13 D. 9 Answer: D. 9 Rationale: The Braden Scale ranges from 6 to 23, with lower scores indicating higher risk. A score below 12 suggests high risk for pressure injuries. 3. Select all that apply: Which factors place a patient at greater risk for developing pressure injuries? A. Poor circulation B. Regular position changes C. Poor hygiene D. Dermatitis E. Balanced nutrition Answers: A, C, and D Rationale: Poor circulation, poor hygiene, and skin conditions like dermatitis increase the risk of skin breakdown and pressure injuries. Regular position changes and balanced nutrition help reduce this risk. 4. A patient has a Braden Scale score of 11. Which interventions should the nurse include in the patient's care plan to prevent pressure injuries? (Select all that apply.) A. Reposition the patient every 2 hours. B. Use absorbent pads to manage incontinence. C. Apply lotion to keep the skin dry. D. Encourage the patient to use a trapeze bar to shift weight. E. Massage reddened areas to improve circulation. Answers: A, B, and D Rationale: Regular repositioning, incontinence management, and encouraging movement reduce pressure injury risk. Applying lotion to keep skin dry is incorrect; lotion keeps skin moist, and massaging reddened areas can cause further tissue damage. 5. A nurse assesses a bedridden patient and finds a non-blanchable red area on the sacrum. Which stage of pressure injury does this finding indicate? A. Stage 1  B. Stage 2 C. Stage 3 D. Stage 4 Answer: A. Stage 1 Rationale: A non-blanchable red area on intact skin indicates a Stage 1 pressure injury. 6. During a skin assessment, the nurse observes a full-thickness wound on a patient’s heel with slough covering the wound bed, obscuring the extent of damage. How should the nurse document this finding? A. Stage 2 pressure injury B. Unstageable pressure injury C. Stage 3 pressure injury D. Deep tissue pressure injury Answer: B. Unstageable pressure injury Rationale: When slough or eschar obscures the wound bed and prevents depth assessment, it is documented as an unstageable pressure injury. 7. A patient’s Braden Scale score reflects limited sensory perception, impaired mobility, and very moist skin. Which nursing intervention is most appropriate? A. Decreasing the frequency of repositioning. B. Keeping the head of the bed elevated at 45 degrees. C. Placing a foam mattress overlay on the patient’s bed. D. Performing frequent massages to improve circulation. Answer: C. Placing a foam mattress overlay on the patient’s bed. Rationale: A foam mattress overlay can help reduce pressure on bony prominences, especially in patients with limited mobility and sensory perception. Repositioning frequency should increase, not decrease; elevating the head too high increases pressure on the sacrum. 8. A patient has a Braden Scale score of 10. Which interventions should the nurse implement to address skin moisture? (Select all that apply.)  A. Use barrier cream to protect the skin. B. Apply a heating pad to the sacrum. C. Check and change absorbent pads frequently. D. Keep the skin hydrated with regular lotion application. E. Avoid using any skin protectants. Answers: A and C Rationale: Using a barrier cream protects the skin from moisture-related damage, and changing absorbent pads frequently helps maintain dry skin. 9. Which finding would indicate that a patient with a Stage 3 pressure injury is healing? A. Appearance of granulation tissue in the wound bed. B. Development of eschar over the wound. C. Increased tunneling and undermining. D. Appearance of non-blanchable erythema around the wound edges. Answer: A. Appearance of granulation tissue in the wound bed. Rationale: Granulation tissue indicates the wound is healing by forming new tissue. Eschar development and tunneling are signs of worsening conditions, not healing. A nurse assesses an older adult patient and notices a breakdown in skin integrity on the heels. Which of the following terms best describes this finding? A. Ecchymosis B. Abrasion C. Ulceration D. Excoriation Answer: C. Ulceration Rationale: Ulceration refers to a breakdown in skin integrity with tissue loss, often due to prolonged pressure, especially on areas like the heels in bedridden patients. 2. Tissue Integrity and Perfusion: Impaired Perfusion Question: A nurse is caring for a diabetic patient with a foot wound that is slow to heal. Which underlying issue primarily affects tissue perfusion in this patient? A. Hypercalcemia B. Poor blood circulation C. Hyperglycemia D. Dehydration Answer: B. Poor blood circulation Rationale: Diabetic patients commonly experience decreased peripheral circulation, especially in the extremities, which impairs perfusion and slows wound healing. 3. Tissue Integrity: Skin Breakdown Risk Factors Question: Which of the following factors place a patient at increased risk for skin breakdown? (Select all that apply) A. Immobility B. Excessive moisture C. Dehydration D. Regular use of emollients E. Advanced age Answer: A, B, C, E Rationale: Immobility, excessive moisture, dehydration, and advanced age increase the risk of skin breakdown due to reduced mobility, fragile skin, and inadequate hydration. 4. Integumentary and Peripheral Vascular Systems: Connection Question: A nurse is assessing a patient with peripheral vascular disease (PVD) who also exhibits dry, flaky skin on their lower legs. What is the best explanation for the connection between these findings? A. Dry skin is common in older adults B. Impaired blood flow reduces moisture delivery to tissues C. PVD does not impact the integumentary system D. These findings are unrelated Answer: B. Impaired blood flow reduces moisture delivery to tissues Rationale: Peripheral vascular disease impairs blood flow, limiting oxygen and nutrient delivery to the skin, resulting in dryness and flakiness. 5. Lymph System: Function and Assessment Question: When assessing the lymphatic system, a nurse finds enlarged lymph nodes in the patient’s neck. Which of the following actions should the nurse take next? A. Assume it is a normal finding B. Document it as lymphadenopathy C. Ignore the finding if the patient has no pain D. Ask about recent infections or inflammation Answer: D. Ask about recent infections or inflammation Rationale: Enlarged lymph nodes (lymphadenopathy) often indicate infection or inflammation, so exploring recent health history helps identify potential causes. 6. Lifespan Variations: Pediatric Integumentary System Question: A nurse assesses the skin of a newborn and notices thin, translucent skin. What does the nurse know about this finding? A. It indicates dehydration B. It is an abnormal finding in newborns C. It is a normal finding due to the immaturity of the skin D. It suggests a need for immediate intervention Answer: C. It is a normal finding due to the immaturity of the skin Rationale: Newborns have thin, translucent skin as part of normal development, and their skin gradually thickens with age. 7. Lifespan Variations: Aging Skin Question: An elderly patient presents with fragile, easily bruised skin. The nurse understands that these findings are related to: A. Increased collagen production B. Increased subcutaneous fat C. Decreased skin elasticity and thinning D. Increased hydration Answer: C. Decreased skin elasticity and thinning Rationale: Aging leads to a reduction in skin elasticity, collagen, and subcutaneous fat, making skin fragile and prone to bruising. 8. Assessment Tools for Skin Breakdown: Braden Scale Question: A nurse uses the Braden Scale to assess a patient’s risk for skin breakdown. Which of the following factors does this tool evaluate? (Select all that apply) A. Sensory perception B. Skin color C. Mobility D. Nutrition E. Age Answer: A, C, D Rationale: The Braden Scale assesses risk factors for skin breakdown, including sensory perception, mobility, and nutrition. Age is not a direct criterion, though it may influence overall risk. 9. Health Promotion: Preventing Peripheral Vascular Issues Question: A nurse is teaching a patient with peripheral vascular disease about ways to prevent further complications. Which health promotion activity should the nurse recommend? A. Avoiding all exercise B. Smoking cessation C. Wearing tight, supportive shoes D. Increasing sodium intake Answer: B. Smoking cessation Rationale: Smoking exacerbates peripheral vascular disease by further constricting blood vessels, so quitting can improve circulation. 10. Health Promotion: Skin Health Question: Which advice should a nurse give a patient to maintain healthy skin? A. Limit water intake to reduce skin moisture B. Use sunscreen daily to protect against UV damage C. Avoid moisturizing to prevent oily skin D. Increase sun exposure for vitamin D Answer: B. Use sunscreen daily to protect against UV damage Rationale: Sunscreen protects the skin from harmful UV rays, reducing the risk of skin damage and skin cancer. 11. Critical Thinking: Newborn Skin Assessment Question: A nurse assesses a 2-day-old newborn and notices a pink, blotchy rash on the chest. What is the nurse’s best response? A. Document it as erythema toxicum, a common newborn rash B. Notify the healthcare provider immediately C. Apply an antibacterial cream D. Restrict all skin contact to avoid spread Answer: A. Document it as erythema toxicum, a common newborn rash Rationale: Erythema toxicum is a common, harmless rash in newborns that typically resolves on its own. 12. Expected Variations in Integumentary System Question: Which of the following skin findings would be expected in an elderly client? A. Oily skin and acne B. Decreased skin turgor and increased dryness C. Thickening of the epidermis D. Increased production of collagen Answer: B. Decreased skin turgor and increased dryness Rationale: Elderly clients commonly experience decreased skin turgor and increased dryness due to reduced moisture retention. 13. Critical Thinking: Infant Circulation Question: A nurse assessing a newborn notices slight cyanosis in the hands and feet. What should the nurse do next? A. Document it as normal acrocyanosis B. Prepare for resuscitation C. Place the baby under a warmer D. Notify the healthcare provider immediately Answer: A. Document it as normal acrocyanosis Rationale: Acrocyanosis, or bluish discoloration of hands and feet, is common in newborns and usually resolves on its own. 14. Integumentary Assessment: Skin Turgor Question: The nurse pinches the skin on the back of a patient’s hand to assess turgor. Slow return to normal position may indicate: A. Good hydration B. Dehydration C. Poor perfusion D. Normal aging Answer: B. Dehydration Rationale: Poor skin turgor with slow recoil is a sign of dehydration. 15. Peripheral Vascular System: Expected Findings Question: A nurse assesses the pedal pulses of an older adult patient and notes they are weak but present. The nurse should: A. Document as a normal age-related finding B. Elevate the patient’s legs above the heart C. Report as an emergency D. Apply a warm compress to improve circulation Answer: A. Document as a normal age-related finding Rationale: Weaker pedal pulses can be normal in older adults due to reduced peripheral circulation. 16. Lymph System: Assessment for Edema Question: A nurse notes 2+ pitting edema in a patient’s lower extremities. This finding may indicate: A. Dehydration B. Lymphatic obstruction C. Good perfusion D. Poor dietary intake Answer: B. Lymphatic obstruction Rationale: Edema, particularly pitting, can indicate lymphatic obstruction or venous insufficiency. 17. Integumentary Health Promotion: Diabetic Skin Care Question: Which advice should a nurse give to a diabetic patient for skin care? A. Avoid daily foot inspections B. Moisturize feet, but avoid the area between toes C. Use alcohol-based products to disinfect feet D. Walk barefoot to toughen skin Answer: B. Moisturize feet, but avoid the area between toes Rationale: Diabetics should moisturize to prevent dryness but avoid the area between toes to reduce infection risk. 18. Skin Integrity Assessment: Color Changes Question: The nurse notes that a patient’s skin appears dusky and discolored. This color change may indicate: A. Good circulation B. Impaired perfusion C. Increased oxygenation D. Normal findings in all adults Answer: B. Impaired perfusion Rationale: Dusky skin can be a sign of decreased blood flow or oxygenation, indicating impaired perfusion. 19. Assessment Tools: Norton Scale Question: A nurse uses the Norton Scale to assess skin breakdown risk. What does a low score indicate? A. High risk for skin breakdown B. Minimal risk for skin breakdown C. High mobility level D. Low hydration level Answer: A. High risk for skin breakdown Rationale: Lower Norton Scale scores indicate a higher risk for skin breakdown. 20. Critical Thinking: Signs of Venous Insufficiency Question: A nurse assesses a patient with swollen, darkened skin around the lower legs and ankles. The nurse suspects: A. Arterial insufficiency B. Venous insufficiency C. Dehydration D. Normal age-related change Answer: B. Venous insufficiency Rationale: Darkened, swollen skin around the ankles often indicates venous insufficiency. Question: A nurse assesses capillary refill in a patient and notes that it takes 4 seconds for color to return to the nail bed. Which term best describes this finding? A. Normal perfusion B. Compromised perfusion C. Tissue integrity D. Hyperperfusion Answer: B. Compromised perfusion Rationale: Capillary refill time greater than 2 seconds may indicate compromised perfusion, suggesting reduced blood flow to the extremities. 2. Key Terms: Tissue Integrity Question: When assessing tissue integrity, which of the following findings would be concerning? A. Intact skin without redness B. Erythema and skin that does not blanch C. Warm, dry skin with normal texture D. Moist skin with normal color Answer: B. Erythema and skin that does not blanch Rationale: Non-blanching erythema is an early sign of skin breakdown and potential pressure ulcer formation, indicating compromised tissue integrity. 3. Connections Between Systems: Integumentary and Vascular Systems Question: A patient with peripheral artery disease (PAD) has cold, pale extremities and diminished pedal pulses. What integumentary finding would the nurse expect to see? A. Warm skin B. Thickened skin C. Dry, thin skin D. Red, swollen skin Answer: C. Dry, thin skin Rationale: PAD often leads to dry, thin skin due to decreased blood flow and poor nutrient delivery, affecting skin health. 4. Connections Between Systems: Temperature Changes Question: In assessing a patient with peripheral vascular disease, the nurse notes cool skin on the legs. Which system interaction is most likely responsible for this finding? A. Nervous and lymphatic systems B. Integumentary and vascular systems C. Muscular and skeletal systems D. Lymphatic and gastrointestinal systems Answer: B. Integumentary and vascular systems Rationale: The vascular system affects blood flow, which impacts skin temperature and perfusion in the integumentary system. 5. Lymph System: Function Question: A nurse explains the function of the lymphatic system to a client. Which statement indicates the client understands the lymph system’s role? A. “It transports oxygen to cells.” B. “It filters out bacteria and removes waste.” C. “It generates new red blood cells.” D. “It stores excess water for dehydration.” Answer: B. “It filters out bacteria and removes waste.” Rationale: The lymphatic system filters bacteria and other pathogens, removing waste and maintaining fluid balance. 6. Lymph System: Assessment of Lymph Nodes Question: The nurse palpates the lymph nodes in a patient’s neck and finds them to be enlarged, firm, and tender. This finding is most indicative of: A. Lymphoma B. Inflammation or infection C. Dehydration D. Fluid overload Answer: B. Inflammation or infection Rationale: Enlarged, firm, and tender lymph nodes often indicate a response to infection or inflammation. 7. Lifespan Variations: Pediatric Skin Integrity Question: A nurse assesses a toddler with a rash on the diaper area. The skin is red, moist, and macerated. What advice should the nurse provide to the parent? A. Limit diaper changes to twice a day B. Use a barrier cream at each diaper change C. Increase the amount of soap used D. Apply powder to the affected area Answer: B. Use a barrier cream at each diaper change Rationale: Barrier creams protect the skin from moisture, which can prevent diaper rash and support skin integrity in children. 8. Lifespan Variations: Skin Changes in Adolescents Question: A teenager presents with oily skin and acne. The nurse knows this is a common change due to: A. Increased blood flow B. Hormonal changes C. Decreased hydration D. Slower skin cell turnover Answer: B. Hormonal changes Rationale: Adolescence brings hormonal changes that increase oil production in the skin, often resulting in acne. 9. Assessment Tools: Pediatric Risk for Skin Breakdown Question: Which tool is commonly used to assess pediatric patients for risk of skin breakdown? A. Braden Scale B. Norton Scale C. Waterlow Score D. Pediatric Braden Q Scale Answer: D. Pediatric Braden Q Scale Rationale: The Pediatric Braden Q Scale is designed to assess risk for skin breakdown in pediatric populations. 10. Assessment Tools: Adult Skin Breakdown Risk Question: A nurse is assessing an adult patient’s skin breakdown risk. Which of the following factors on the Braden Scale would indicate an increased risk? (Select all that apply) A. Limited mobility B. Adequate nutrition C. Sensory impairment D. Frequent repositioning E. High moisture levels on skin Answer: A, C, E Rationale: Limited mobility, sensory impairment, and high moisture levels increase the risk of skin breakdown. Adequate nutrition and frequent repositioning help lower the risk. 11. Health Promotion: Preventing Peripheral Vascular Issues Question: A nurse is educating a patient with varicose veins on preventive measures. Which recommendation is appropriate? A. Avoid exercise B. Elevate the legs when sitting C. Wear tight, non-stretchable clothing D. Limit water intake Answer: B. Elevate the legs when sitting Rationale: Elevating the legs promotes venous return and reduces pressure on leg veins, preventing venous pooling and worsening varicose veins. 12. Health Promotion: Skin Hydration Question: The nurse advises a patient on proper skin hydration. Which action should the patient take to maintain skin moisture? A. Use hot water when bathing B. Apply moisturizer after bathing C. Avoid using any skin creams D. Only wash with soap once a week Answer: B. Apply moisturizer after bathing Rationale: Applying moisturizer after bathing helps retain skin moisture and prevent dryness. 13. Critical Thinking: Risk of Skin Breakdown in Elderly Patient Question: An elderly, immobile patient is at risk for skin breakdown. Which nursing intervention would best prevent pressure ulcer formation? A. Increasing protein in the diet B. Applying cold compresses to bony areas C. Repositioning every 2 hours D. Placing a pillow under the knees Answer: C. Repositioning every 2 hours Rationale: Regular repositioning prevents prolonged pressure on one area, reducing the risk of pressure ulcer formation. 14. Critical Thinking: Assessing Tissue Perfusion in a Diabetic Patient Question: A diabetic patient has a foot wound that is slow to heal. Which action should the nurse take to assess tissue perfusion? A. Measure capillary refill time in the toes B. Check the skin temperature of the chest C. Palpate the brachial pulse D. Assess lung sounds Answer: A. Measure capillary refill time in the toes Rationale: Checking capillary refill in the toes helps assess peripheral perfusion in a diabetic patient. 15. Expected Variations in Integumentary and Vascular Systems Question: When assessing an older adult’s skin, the nurse notes thin, dry skin with reduced elasticity. Which explanation should the nurse provide? A. “This finding indicates severe dehydration.” B. “This is a common age-related skin change.” C. “This is an abnormal finding and requires immediate care.” D. “This means the skin is unusually well hydrated.” Answer: B. “This is a common age-related skin change.” Rationale: Aging skin typically becomes thinner, drier, and less elastic due to changes in collagen and moisture levels.