Skin/Hair/Nails
The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the epidermal layer of the skin should be included in the module?
A. Highly vascular
B. Thick and tough
C. Thin and nonstratified
D. Replaced every 4 weeks
ANS: D
The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones. The epidermis is avascular, not highly vascular; thin and tough, not thick; and stratified into several zones, not nonstratified. The epidermis is also replaced every 4 weeks.
The nurse is testing a patient’s visual accommodation. How is accommodation assessed?
A. Pupillary dilation when looking at a distant object
B. Involuntary blinking in the presence of bright light
C. Pupillary constriction when looking at a near object
D. Changes in peripheral vision in response to bright light
ANS: C
The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.
When examining the ear with an otoscope, how should the tympanic membrane look?
A. Light pink with a slight bulge
B. Pearly gray and slightly concave
C. Whitish with black flecks or dots
D. Pulled in at the base of the cone of light
ANS: B
The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles. A light pink color and a slight bulge of the tympanic membrane indicate otitis media. It should not look white and if there are tiny black flecks or dots, that is indicative of a fungal infection, or otomycosis. The tympanic membrane does not appear pulled in at the base of the cone of light, but should instead appear flat and slightly pulled in at the center. A normal tympanic membrane should appear a pearly gray color and have a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.
In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings?
A. Refer the patient to a throat specialist.
B. No response is needed; this appearance is normal for the tonsils.
C. Continue with the assessment, looking for any other abnormal findings.
D. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. There is no need to refer the patient to a throat specialist, obtain a throat culture, or look for other abnormal findings because the findings in this question are normal. Although the tonsils look more granular and their surface shows deep crypts, they are the same color as the surrounding mucous membrane and tonsillar tissue enlarges during childhood until puberty and then involutes.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
A. Color variation
B. Border regularity
C. Symmetry of lesions
D. Diameter of less than 6 mm
ANS: A
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odor.” The nurse knows that this is likely r/t a disorder with what part of the body?
A. Eccrine glands
B. Apocrine glands
C. Disorder of the stratum corneum
D. Disorder of the stratum germinativum
ANS: A
The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient’s statement is not r/t disorders of the stratum corneum or the stratum germinativum. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The part of the body that produces sweat are the eccrine glands.
The nurse is reviewing the age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?
A. Loss of lens elasticity
B. Degeneration of the cornea
C. Decreased adaptation to darkness
D. Decreased distance vision abilities
ANS: A
The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.
A patient with a middle ear infection asks the nurse, “What does the middle ear do?” Which is the best response by the nurse?
A. It helps maintain balance.
B. It interprets sounds as they enter the ear.
C. It conducts vibrations of sounds to the inner ear.
D. It increases the amplitude of sound for the inner ear to function.
ANS: C
Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear. The inner ear, not the middle ear, helps with balance. Sound is interpreted in the cerebral cortex, not the middle ear. The middle ear reduces the amplitude of loud sounds, not increase them, to protect the inner year. The functions of the middle ear are to conduct sound vibrations from the outer ear to the central hearing apparatus in the inner ear; protect the inner ear by reducing the amplitude of loud sounds; and allow equalization of air pressure on each side of the tympanic membrane via the eustachian tubes so that the membrane does not rupture.
What is the primary purpose of the ciliated mucous membrane in the nose?
A. To warm the inhaled air
B. To filter out dust and bacteria
C. To filter coarse particles from inhaled air
D. To facilitate the movement of air through the nares
ANS: C
The nasal hairs, or cilia, filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. The rich blood supply of the nasal mucosa warms the inhaled air, not the ciliated mucous membrane. The mucous blanket, not the cilia, filters out dust and bacteria. The cilia in the nose do not facilitate the movement of air through the nares. Instead, the nasal hairs, or cilia, filter the coarsest matter from inhaled air.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
A. Refer the patient to an ophthalmologist or optometrist for further evaluation.
B. Assess whether the patient can count the nurse’s fingers when they are placed in front of his or her eyes.
C. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again.
D. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
ANS: D
If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., “10/200”). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity. The nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight only if unable to see the letters on the Snellen chart when the distance is shortened. Applying reading glasses will not help with reading the Snellen chart as that is assessing far vision, not near vision.
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be r/t which factor in the older adult?
A. Increased vascularity of the skin
B. Increased numbers of sweat and sebaceous glands
C. An increase in elastin and a decrease in subcutaneous fat
D. An increased loss of elastin and a decrease in subcutaneous fat
ANS: D
An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. With aging there is a decrease in the vascularity, number of sweat and sebaceous glands, and elastin not an increase.
A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. How should the nurse proceed?
A. Examine the retina to determine the number of floaters.
B. Presume the patient has glaucoma and refer him for further testing.
C. Consider these to be abnormal findings, and refer him to an ophthalmologist.
D. Understand that floaters are usually insignificant and are caused by condensed vitreous fibers.
ANS: D
Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment. The floaters or spots would not be visible for the nurse to see or count. A decrease in peripheral vision is a symptom of glaucoma, not floaters.
The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?
ANS: VIII
The nerve impulses are conducted by the auditory portion of CN VIII to the brain. Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Cranial nerve III, the oculomotor, innervates the superior, inferior, and medial rectus and the inferior oblique muscles of the eye. Cranial nerve XI, the accessory nerve, controls the muscles of the neck. The nerve that conducts nerve impulses from the organ of Corti to the brain is CN VIII, the vestibulocochlear nerve.
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse’s best response?
A. “While sitting up, place a cold compress over your nose.”
B. “Sit up with your head tilted forward and pinch your nose.”
C. “Allow the bleeding to stop on its own, but don’t blow your nose.”
D. “Lie on your back with your head tilted back and pinch your nose.”
ANS: B
With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?
A. “It is unusual for a small child to have frequent ear infections unless something else is wrong.”
B. “We need to check the immune system of your son to determine why he is having so many ear infections.”
C. “Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear.”
D. “Your son’s eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.”
ANS: D
The infant’s eustachian tube is relatively shorter and wider than the adult’s eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate. It is not unusual for a small child to have frequent ear infections, thus, it is not necessary to check the immune system. The reason that ear infections in infants and toddlers is not uncommon is not due to more cerumen but because the infant’s eustachian tubes are relatively shorter and wider than the adult’s eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and is prescribed oral hypoglycemic agents. What should the nurse include in this patient’s teaching?
A. Increased possibility of bruising
B. Importance of sunscreen and avoiding direct sunlight
C. Lack of availability of glucose-monitoring equipment
D. Skin sensitivity because of exposure to salt water
ANS: B
Oral hypoglycemic agents may increase sunlight sensitivity and could result in sunburn. Other drugs that increase sunlight sensitivity include sulfonamides, thiazide diuretics, and tetracycline. Oral hypoglycemic agents are not associated with increased bruising. Glucose-monitoring equipment is readily available in retail stores. Exposure to salt water does not typically cause skin sensitivity. However, oral hypoglycemic agents and other drugs such as sulfonamides, thiazide diuretics, and tetracycline may increase sunlight sensitivity and cause sunburn.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?
A. Perform the confrontation test.
B. Ask the patient to read the print on a handheld Jaeger card.
C. Use the Snellen chart positioned 20 feet away from the patient.
D. Determine the patient’s ability to read newsprint at a distance of 12 to 14 inches.
ANS: C
The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.
During an interview, the patient states he has the sensation that “everything around him is spinning.” What part of the ear should the nurse recognize is responsible for this sensation?
A. Cochlea
B. CN VIII
C. Labyrinth
C. Organ of Corti
ANS: C
If the labyrinth of the ear becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo. The cochlea, which contains the central hearing apparatus, and cranial nerve VIII, the vestibulocochlear nerve, which conducts nerve impulses from the organ of Corti to the brain, are all involved with hearing. The spinning sensation that this patient is experiencing is from the labyrinth of the ear.
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
A. Avoiding touching the nasal septum with the speculum
B. Inserting the speculum at least 3 cm into the vestibule
C. Gently displacing the nose to the side that is being examined
D. Keeping the speculum tip medial to avoid touching the floor of the nares
ANS: A
The correct technique for using an otoscope to examine the nasal cavity is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
A. Color variation
B. Border regularity
C. Symmetry of lesions
D. Diameter of less than 6 mm
ANS: A
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
The nurse keeps in mind that a thorough skin assessment is extremely important. What can the skin provide important information about?
A. Support systems
B. Circulatory status
C. Socioeconomic status
D. Psychological wellness
ANS: B
The skin holds information about the body’s circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself. Assessment of the skin does not typically provide information on support systems, socioeconomic status, or psychological wellness.
A patient’s vision is recorded as 20/80 in each eye. How does the nurse interpret this finding?
A. Patient has presbyopia.
B. Patient as poor vision.
C. Patient has acute vision.
D. Patient has normal vision.
ANS: B
Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision. Presbyopia is a decrease in accommodation which is observed by convergence (motion toward) of the axes of the eyeballs and pupillary constriction and is tested by having the person focus on a distant object.
The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?
A. Tilt the person’s head forward during the examination.
B. Once the speculum is in the ear, releasing the traction.
C. Pulling the pinna up and back before inserting the speculum.
D. Using the smallest speculum to decrease the amount of discomfort.
ANS: C
The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. The nurse should tilt the patient’s head slightly away from them and toward the opposite shoulder, not forward. The traction on the pinna of the ear should not be released until the examination is finished and the otoscope has been removed. The largest speculum that fits comfortably in the ear, not the smallest, should be used. The correct action is to pull the pinna up and back on an adult or older child (down and back on an infant or child under the age of 3), which helps straighten the S-shape of the canal.
When assessing the tongue of an adult, what finding would be considered abnormal?
A. Smooth glossy dorsal surface
B. Thin white coating over the tongue
C. Raised papillae on the dorsal surface
D. Visible venous patterns on the ventral surface
ANS: A
The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas are abnormal and may indicate atrophic glossitis.
During an assessment, a patient mentions that “I just can’t smell like I used to. I can barely smell the roses in my garden. Why is that?” For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.)
A. Aging
B. Chronic allergies
C. Cigarette smoking
D. Chronic alcohol use
E. Herpes simplex virus I
F. Frequent episodes of strep throat
ANS: A, B, C
The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell. Chronic alcohol use, herpes simplex virus I, and frequent episodes of strep throat do not common causes of a diminished sense of smell. The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.