NCLEX Ch 9
NCLEX Practice Questions: Tissue Integrity and Integumentary System
1. A nurse is assessing a client with dark skin for signs of jaundice. Which area should the nurse inspect to provide the most accurate assessment?
A. Fingerprints and palms
B. Sclera of the eyes
C. Skin of the abdomen
D. Nail beds
Answer: B. For individuals with dark skin, jaundice is most easily seen in the sclera. It is important not to confuse this with normal yellow eye pigmentation.
2. A nurse is caring for an immobile patient and observes an area of redness on the sacrum. The nurse applies pressure and the area does not blanch. What is the correct classification for this injury?
A. Reactive hyperemia
B. Stage 1 pressure injury
C. Stage 2 pressure injury
D. Deep tissue pressure injury
Answer: B. Stage 1 is characterized by a localized area of non-blanchable redness of intact skin. If it blanched, it would likely be reactive hyperemia.
3. A nurse is evaluating a client for melanoma using the ABCDE mnemonic. What does the 'E' represent?
A. Erythema
B. Elevation
C. Evolving
D. Exudate
Answer: C. E stands for Evolving, which refers to a skin lesion that looks different from others or is changing in size, shape, or color.
4. A nurse is assessing a patient with a history of chickenpox who now presents with painful, linearly grouped vesicles along a dermatome. Which condition does this characterize?
A. Herpes simplex
B. Herpes zoster
C. Pityriasis rosea
D. Impetigo
Answer: B. Herpes zoster (shingles) is caused by the reactivation of the dormant varicella (chickenpox) virus and typically follows a sensory nerve line (dermatome).
5. A patient presents with a 'bullseye' rash (erythema with central clearing) larger than 5\text{ cm}. The nurse should suspect which of the following?
A. Tinea corporis
B. Lyme disease
C. Psoriasis
D. Contact dermatitis
Answer: B. A bullseye rash (erythema migrans) larger than 5\text{ cm} is a classic sign of Lyme disease, often following an infected tick bite.
6. Which skin cancer is most common and characterized by a nodular pigmented lesion with depressed centers and rolled borders?
A. Squamous cell carcinoma
B. Malignant melanoma
C. Basal cell carcinoma
D. Kaposi's sarcoma
Answer: C. Basal cell carcinoma is the most common form of skin cancer and often presents with depressed centers and rolled borders.
7. A nurse observes a red, scaly patch with a sharply demarcated border and a central ulcer on a patient's head. The nurse knows this is likely:
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Psoriasis
D. Contact dermatitis
Answer: B. Squamous cell carcinoma often appears as a red, scaly patch with a sharp border and may develop a central ulcer as it matures.
8. When assessing for child abuse, the nurse identifies a 'stocking' pattern burn on the child’s feet. This is an example of what type of burn?
A. Contact burn
B. Glancing burn
C. Immersion burn
D. Accidental splash burn
Answer: C. Immersion burns occur when a child is placed in scalding water, resulting in a clear line of demarcation (glove or stocking pattern).
9. A patient complains of intense itching at night. The nurse finds linear burrows between the fingers. What is the appropriate diagnosis?
A. Pediculosis
B. Tinea pedis
C. Scabies
D. Folliculitis
Answer: C. Scabies, caused by mites, is characterized by severe nocturnal pruritus and the presence of small, linear burrows.
10. A nurse is assessing a patient with silvery scales on their elbows and knees. When the patient scratches the scales, small bleeding points are seen. This is indicative of:
A. Seborrheic dermatitis
B. Atopic dermatitis
C. Psoriasis
D. Pityriasis rosea
Answer: C. Psoriasis presents with silvery scales on erythematous plaques. Bleeding points after scratching (Auspitz sign) are a specific characteristic.
11. Which layer of the skin acts as an anchor for the upper layers and contains fat cells to help retain heat and provide a protective cushion?
A. Epidermis
B. Dermis
C. Subcutaneous layer (Hypodermis)
D. Stratum germinativum
Answer: C. The subcutaneous layer is a support structure composed of connective tissue and fat that anchors the dermis and epidermis.
12. A patient presents with a single 'herald patch' on the trunk. The nurse anticipates that in 1 to 3 weeks, the patient will develop a generalized eruption. This is the progression for:
A. Tinea cruris
B. Pityriasis rosea
C. Herpes simplex type 1
D. Cellulitis
Answer: B. Pityriasis rosea starts with a herald patch and is followed weeks later by a generalized macular eruption on the trunk.
13. A patient has a yellow, crumbling nail with hyperkeratotic debris. The nurse identifies this as:
A. Paronychia
B. Hirsutism
C. Onychomycosis
D. Clubbing
Answer: C. Onychomycosis is a fungal infection of the nail plate that causes it to turn yellow or white and eventually crumble.
14. A nurse finds a bruise on a patient's arm that is green and brown in color. The nurse estimates the bruise is approximately how many days old?
A. 1 to 3 days
B. 3 to 6 days
C. 6 to 15 days
D. Over 20 days
Answer: B. Bruises that are 3 to 6 days old appear green to brown. Purple/black bruises are newer (1-3 days), and yellow/tan bruises are older (6-15 days).
15. Which glands are primarily concentrated on the palms, soles, and forehead, and are responsible for regulating body temperature?
A. Apocrine glands
B. Sebaceous glands
C. Eccrine glands
D. Thyroid glands
Answer: C. Eccrine sweat glands are the most numerous and are used for thermoregulation through the secretion of water.