ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 64 : Introduction to the Integumentary System Questions
Question 1 of 5
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.
Question 2 of 5
The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review?
Correct Answer: A
Rationale: Normal nails appear slightly convex with a 160?° angle between the nail base and the skin. Concave-shaped nails, referred to as 'spooning' because of their characteristic appearance, are a sign of iron-deficiency anemia. ABGs, BUN and creatinine, and glucose levels are not related to this shape of nail.
Question 3 of 5
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
Correct Answer: D
Rationale: Clubbing of the nails is evidenced by an angle greater than 160?° and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or 'spooning' may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.
Question 4 of 5
A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination using ultraviolet light can be used to determine if the rash is a fungal rash?
Correct Answer: D
Rationale: A Wood light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light; the others use skin scrapings.
Question 5 of 5
A client has a wart on the left knee but wants to try an over-the-counter medication to dissolve the wart. What type of solution would the nurse educate the client about?
Correct Answer: D
Rationale: Keratolytics dissolve thickened, cornified skin such as warts, corns, and calluses. Their action causes the treated area to soften and swell, facilitating removal. Antiseborrheic agents are applied to the scalp or incorporated into shampooing products to control dandruff. Antihistamines are used to relieve itching. An antiseptic would be used to reduce bacteria on the arm.