ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 60 : Assessment of Integumentary Function Questions
Question 1 of 5
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
Correct Answer: D
Rationale: Jaundice, caused by elevated serum bilirubin, is best observed in the sclerae and mucous membranes, especially in darker-skinned individuals where skin pigmentation may mask changes.
Question 2 of 5
A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?
Correct Answer: B
Rationale: A new rash during antibiotic therapy suggests a possible allergic reaction, which could be life-threatening. Assessing for allergies is the priority over timing, sensation, or pain.
Question 3 of 5
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
Correct Answer: B
Rationale: Aging causes thinning at the dermis-epidermis junction, increasing the risk of shearing injuries. Moisturizers are beneficial for dry skin, ice packs can be used with caution, and sweat accumulation is not a concern in older adults.
Question 4 of 5
A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient?
Correct Answer: B
Rationale: Ecchymosis, or bruising, is a risk with anticoagulants like warfarin due to blood extravasation. Ulcers, scars, and erosions are not directly associated with anticoagulant use.
Question 5 of 5
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?
Correct Answer: C
Rationale: Patch testing identifies allergens causing contact dermatitis. Skin scrapings are for fungal infections, biopsies rule out malignancy, and Tzanck smears diagnose blistering conditions.