Test bank for ebersole and hessu2019 gerontological nursing healthy aging 4th edition by touhy

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Ebersole and Hess’ Gerontological Nursing & Healthy Aging: 4th
Edition Test Bank – Touhy
Sample
Chapter 12: Promoting Healthy Skin and Feet
Test Bank

MULTIPLE CHOICE

1. Which of the following is an important consideration about the skin of an older
adult person?
a.

Generous amounts of soap should be used for cleansing.

b.

Sweat gland activity increases.

c.

Skin becomes more vulnerable to damage.

d.

Skin becomes darker in unexposed areas.

ANS: C
Thin skin–reduced sebaceous protection, vascular insufficiency, and longer periods in

stationary positions promote skin damage for older adults. Because moisture is lost more




rapidly from the skin of an older adult, excessive use of soap tends to dehydrate the skin
more severely than it does in a younger person. Sweat gland activity does not increase in
older age, but moisture is lost more rapidly because the skin is thinner and sebum
secretion is reduced. Changes of skin color in areas exposed to the sun are of greater
concern than those in unexposed areas.

PTS: 1

DIF:

Remember

TOP: Nursing Process: Assessment

REF: 184-186
MSC: Health Promotion and Maintenance

2. A dermatologist should promptly evaluate which one of the following skin
lesions?
a.

Circumscribed, raised area resembling a blob of brown
wax

b.

Multicolored raised lesion with a fuzzy border

c.

Bright red, glazed area with satellite lesions around it

d.

Brown spot on the skin with no raised area

ANS: B
A multicolored raised lesion with a fuzzy border must be promptly evaluated; this lesion
is a malignant melanoma. A circumscribed, raised area resembling a blob of brown wax
reflects seborrheic keratosis. A bright red, glazed area with satellite lesions around it is
a Candida infection. A brown spot on the skin with no raised area is lentigo.




PTS: 1

DIF:

Understand

TOP: Nursing Process: Assessment

REF: 186-188
MSC: Health Promotion and Maintenance

3. Which topical agent is safe to apply?
a.

Cornstarch to absorb moisture in the groin area

b.

Betadine to disinfect a healing pressure ulcer

c.

An over-the-counter preparation to dissolve a corn

d.

Light mineral oil to moisten skin after bathing

ANS: D
Light mineral oil to moisten skin after bathing helps replace the sebum layer and retain
the moisture in the skin. Cornstarch is a substance that promotes fungal growth. Betadine,
hydrogen peroxide, alcohol, and some soaps are damaging to newly formed skin. Corn
preparations dissolve healthy tissue along with the corn.

PTS: 1
Evaluation

DIF:

Understand

REF: 184-185

TOP: Nursing Process:

MSC: Safe, Effective Care Environment

4. An older patient complains of dry skin and asks for advice. Which advice should
the nurse offer for improving dry skin?




a.

Add oil to the bath water to keep skin soft.

b.

Use tepid bath water.

c.

Move to a climate with lower humidity.

d.

Vigorously dry skin with a rough towel after bathing.

ANS: B

Tepid bath water minimizes moisture loss from skin. Oil added to the bathtub increases
the risk of slipping and falling, which can result in a catastrophic injury. Oils should be
applied directly to moist skin after bathing. Humidity should be maintained at
approximately 60%; the person may not be able to move. Vigorous, rough towel drying
increases skin irritation.

PTS: 1

DIF:

Apply

REF: 185

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

5. Which of the following is a true statement about impaired skin integrity?
a.

Stage III pressure ulcer cannot regress to stage II because
the subcutaneous tissues regenerate.

b.

Stasis ulcer is another term for pressure ulcer.




c.

Muscle and fat cannot regenerate.

d.

Weight reduction is recommended to help prevent
pressure ulcers.

ANS: C
Because subcutaneous tissues such as muscle and fat are not regenerated but simply
replaced by granular tissue, the staging of pressure ulcers is never reversed. Stasis ulcers
are the result of the leakage of blood from veins beneath the skin. Pressure ulcers are
caused when perfusion to the tissue is impaired by external pressure that causes tissue
injury and death. Sufficient nutrition is essential in maintaining skin integrity.

PTS: 1
Evaluation

DIF:

Remember

REF: 189-193

TOP: Nursing Process:

MSC: Physiological Integrity

6. An older adult woman complains of foot pain from a corn. After assessing her
feet, which intervention should the nurse implement to alleviate her discomfort

safely?
a.

Cut out an oval corn pad to make a U shape.

b.

Use a corn pad slightly larger than the corn.

c.

Gently remove the corn with a sterile razor blade.




d.

Tape her toe with the corn to the other toes.

ANS: A
A corn pad altered this way surrounds the corn without adding pressure over it. If an oval
corn pad is used without being cut to a U shape, then it aggravates pressure over the corn
and can reduce circulation to the covered tissue. For the surgical removal of a corn, the
patient should be referred to the podiatrist. Taping the toes replaces pressure from the
shoe with pressure from the tape.

PTS: 1

DIF:

Apply

REF: 193-196

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

7. Which of the following is a true statement about skin care for older adults?
a.

A licensed practical nurse is qualified to care for the feet
of a patient with diabetes.

b.

Onychomycosis is quickly eradicated with antifungal
creams or powders.

c.

A ram’s-horn nail should be cut to give a smooth,
rounded edge.

d.

Maintaining oral hydration may reduce the incidence of
xerosis.

ANS: D
Oral hydration and lubrication will decrease the incidence of xerosis. Only a registered
nurse who has special training, a nurse practitioner, or a podiatrist should perform
diabetic foot care. The treatment of onychomycosis is difficult because of the limited
blood supply to the nails. Oral medications are expensive and toxic. A toenail should be
cut flat across. Rounding can lead to ingrown toenails.

PTS: 1
Evaluation

DIF:

Remember

REF: 184-196

TOP: Nursing Process:

MSC: Health Promotion and Maintenance

8. The nurse plans care to protect the skin covering an older adult’s greater
trochanter. Which of the following interventions is the nurse’s priority when the
older adult is positioned on the side?
a.

Implement a turning schedule.

b.

Place a cushion between the knees.

c.

Keep the skin clean and dry.

d.

Use the Sims’ position.

ANS: A




The most important nursing intervention when an older adult is positioned on the side is
to relieve pressure on the head of the femur and the greater trochanter; the greater
trochanter is the most prominent bony projection on the side of a body. By turning the
older adult at intervals, the nurse helps maintain tissue perfusion, thus providing
oxygenation to tissues and allowing the removal of waste from vulnerable skin. The nurse
places a pillow between the knees to help maintain physiological body alignment and to
prevent strain on the hips and spine; if positioned properly, the pillow can help maintain
tissue integrity of the medial malleolus and ankle by elevating them off the mattress.
However, because the nurse’s priority is to maintain tissue oxygenation, preventing
muscle and joint strain is not as important. The nurse keeps the skin clean and dry to help
maintain skin integrity, but this intervention is not as important as maintaining tissue
oxygenation. The nurse uses the Sims’ position to supplement turning; when in the Sims’
position, the patient is on the side but rotated slightly forward, allowing the chest and
abdomen to fall forward to relieve some of the pressure on the patient’s side.

PTS: 1

DIF:

Analyze

REF: 184-193

TOP: Nursing Process: Implementation MSC: Physiological Integrity

9. An older adult is vitamin deficient. Which of the following does the nurse offer to
the older adult to provide the important missing vitamin for maintaining healthy
skin and enhancing tissue repair?
a.

Carrot sticks

c.

Orange slices

b.

Nonfat milk

d.

Unsalted nuts

ANS: C

Orange slices provide vitamin C, which is important for healthy tissues and gums, tissue
repair and healing, and the maintenance of blood vessels. Although carrots sticks are a
good source of beta carotene, fiber, and vitamin A and important in the formation of
epithelial tissue and although milk provides calcium for bone strength and protein for




tissue repair, neither carrots nor milk address vitamin deficiency. Unsalted nuts provide
healthy fats, fiber, and other nutrients but not vitamin C.

PTS: 1

DIF:

Apply

REF: 193

TOP: Nursing Process: Implementation MSC: Physiological Integrity

10. The nurse monitors for which clinical indicator when the older adult complains of
pruritus?
a.

Coarse skin

c.

Brownish skin

b.

Brown macule

d.

Regional edema

ANS: A
The nurse is alert for rough, dry, flaky skin when an older adult complains of pruritus to
be able to prevent linear excoriation leading to skin breaks, excoriation, inflammation,
and infection. A brown macule is a freckle or a liver spot, an indication of sun exposure.
Brownish skin is a clinical indicator of venous insufficiency. Regional edema is a sign of
fluid overload and venous insufficiency; localized edema is a sign of infection.

PTS: 1
Planning

DIF:

Understand

REF: 185

TOP: Nursing Process:

MSC: Health Promotion and Maintenance

11. The nurse cares for an older man who has a malignant melanoma. Which

intervention should the nurse implement for this man to prevent a recurrence or
advancement of this condition in the future?




a.

Place posters about sunscreen in the halls of his
apartment building.

b.

Promote the application of a sunscreen at his
neighborhood health fair.

c.

Tell him to schedule all outdoor activities after 4 PM
daily.

d.

Instruct him to wear sun-protective clothing and a hat at
all times.

ANS: D
The nurse caring for an older adult in acute care instructs him to wear sun-protective
garments at all times to help prevent additional skin cancers, as well as apply an effective
sunscreen to protect his skin against ultraviolet light. Placing posters and promoting

sunscreen at a health fair are interventions for a community nurse. Scheduling activities
after a specific time can be impractical or impossible.

PTS: 1

DIF:

Apply

REF: 186-188

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

12. Which infection-control practice should the nurse implement when caring for an
older adult who has active herpes zoster?




a.

Wear a face shield and gown for all patient contact.

b.

Instruct the staff and visitors to wear a type of respirator
mask.

c.

Use a hospital room that has negative airflow circulation.

d.

Cover ruptured skin lesions with a nonabsorbent dressing.

ANS: D
Herpes zoster in an adult is spread through contact; therefore the nurse applies the
principles of contact precautions when caring for an older adult with active herpes zoster.
To reduce the transmission of the virus through contact, the nurse keeps the ruptured
lesions covered. A face shield is not necessary when caring for an adult with herpes
zoster; however, a gown can be necessary during dressing changes or any time that
splashing can occur. Airborne precautions and a respirator-type mask are indicated for
infections transmitted through the air. Because active herpes zoster in an older adult is
transmitted through contact, negative airflow is not indicated.

PTS: 1

DIF:

Understand

REF: 186

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

13. The nurse is conducting an admission assessment on an older adult and notes a
small lesion with a multicolor appearance. Which assessment approach should the
nurse use?

a.

Braden Scale

b.

Wound staging

c.

ABCD (asymmetry, border, color, diameter) rule

d.

Pressure ulcer scale for healing (PUSH) tool

ANS: C
The ABCD rule is used to assess potential cancerous lesions for asymmetry, border
irregularity, color, and diameter. The Braden Scale is used for predicting pressure ulcers.
Wound staging is used during the assessment of pressure ulcers. The PUSH tool provides
a detailed form that covers all aspects of an assessment.

PTS: 1

DIF:

Apply

TOP: Nursing Process: Assessment

REF: 186-193
MSC: Physiological Integrity

14. A nurse will be conducting an educational session on preventing skin cancer at a
local senior citizens center. Which should the nurse include in the session?
a.

Squamous cell cancer may appear similar to a wart.

b.

Basal cell carcinoma is more common in women.




c.

Actinic keratosis begins as a pearly papule.

d.

Melanoma is characterized by rough, scaly patches.

ANS: A
Squamous cell lesion may appear like a wart and be hard with defined borders. Basal cell
carcinoma is more prevalent in fair-skinned older men and begins as a pearly papule. A

multicolored, raised lesion with asymmetrical borders characterizes melanoma.

PTS: 1
Planning

DIF:

Apply

REF: 187

TOP: Nursing Process:

MSC: Health Promotion and Maintenance

15. Which nursing intervention is most likely to prevent the creation of an
environment conducive to fungal growth?
a.

Provide oral care with soft-bristled brush.

b.

Apply nystatin powder to reddened tissue.

c.

Use mild skin cleansing agents and blot dry.

d.

Apply gauze soaked with antifungal lotion.




ANS: C
Fungal infections are most likely to begin in moist, dark areas of the body such as under
the breasts and at the perineum; thus the nurse works to keep the skin of these areas, as
well as all skin, clean and dry and to prevent tissue irritation from harsh drying.
Providing oral care with a soft-bristled brush is ineffective therapy for preventing an
oral Candida infection (thrush). Besides, thrush is usually an opportunistic infection
caused by immunosuppression. Reddened tissue can be already infected; nonetheless,
applying an antifungal agent is an indicated treatment for a fungal infection. Applying
antifungal lotion and keeping an area moist can contribute to fungal overgrowth.

PTS: 1

DIF:

Understand

TOP: Nursing Process: Assessment

REF: 188
MSC: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet

tall and weighs 155 pounds. Which patient information should the nurse use in
planning care to reduce this individual’s risk for a pressure ulcer? (Select all that
apply.)
a.

Osteoarthritis of neck

b.

Dry mucous membranes

c.

Prealbumin level 7 mg/dl

d.

Fasting glucose 140 mg/dl




e.

Serum sodium 135 mEq/dl

f.

Uses food stamps to get food

ANS: B, C, D, F
One area of concern the nurse should address is the potential for skin breakdown related
to possible pain or immobility due to arthritic changes. The nurse also plans care to
address dehydration as a significant risk factor for pressure ulcers because this man is
underweight, malnourished, and dehydrated as evidenced by dry mucous membranes.
Dehydration increases the risk for pressure ulcers because water is essential for
intracellular functioning and cell durability. The nurse plans care based on the assessment
of hypoproteinemia because this man is underweight and malnourished, significantly
increasing his risk for pressure ulcers.
A fasting glucose showing hyperglycemia is a clinical indicator of diabetes mellitus;
therefore the nurse plans care to manage the hyperglycemia. Diabetes mellitus increases
the risk of pressure ulcers as a result of the greater likelihood of impaired tissue
perfusion, impaired wound healing, and a greater occurrence of peripheral neuropathies.
In addition, impaired tissue sensation as a result of nerve damage from hyperglycemia
increases the risk of injury and infection for individuals with diabetes mellitus. A
characteristic of type 1 diabetes mellitus is a low weight-for-height ratio. This man has
limited resources for obtaining food, considering that he uses food stamps, and is
therefore at risk for malnutrition, which increases the risk for pressure ulcers.
Osteoarthritis in the neck is not related to the nursing care planned to reduce the risk for
pressure ulcers; it should not impair this older adult’s mobility or ability to obtain and
prepare food. His sodium level is within normal limits.

PTS: 1
Planning

DIF:

Apply

REF: 189-193

MSC: Health Promotion and Maintenance

TOP: Nursing Process:




2. Although intact skin effectively protects an individual, it functions within
physiological limits. Which qualities of healthy skin work synergistically within
these limits to absorb, cushion against, deflect, or neutralize potentially harmful
forces, as well as protect against potentially harmful substances that might impair
skin integrity? (Select all that apply.)
a.

Strength

b.

Pliability

c.

Location

d.

Durability

e.

Moistness

f.

Pigmentation

ANS: A, B, D
Skin must be strong enough to withstand forces that can impair its integrity. If skin is not
supple, then it is unable to withstand directional forces and will tear. Skin must be sturdy
enough to act as an effective protective mechanism. All skin must be able to absorb,
cushion, and withstand forces. Skin in a moist environment is subject to bacterial and
fungal overgrowth. Skin pigmentation is unrelated to its ability to cushion, absorb, and
withstand potentially harmful substances and forces.

PTS: 1

DIF:

Understand

REF: 184-185




TOP: Nursing Process: Assessment

MSC: Physiological Integrity

3. Which of the following patient(s) does the nurse identify as at risk for developing
fungal infections? (Select all that apply.)
a.

Obesity

b.

Multiple sclerosis

c.

Impaired mental status

d.

Incontinent

e.

Bedridden

ANS: A, D, E
Prevention is prioritized for persons who are obese, bedridden, incontinent, or
diaphoretic. Patients with multiple sclerosis may develop skin infections but are not at
high risk. Patients with an impaired mental status can often be incontinent, but this
condition, in itself, does not predispose the patient to fungal infections.

PTS: 1

DIF:

Understand

TOP: Nursing Process: Assessment

REF: 188
MSC: Physiological Integrity




4. The nurse identifies which of the following intervention(s) in the treatment of
fungal infections? (Select all that apply.)
a.

Eliminate the conditions that created the problem.

b.

Lubricate affected area daily with moisturizing lotion.

c.

Thoroughly clean and dry skin daily.

d.

Use an antibacterial cleanser daily.

e.

Apply miconazole (Micatin) as directed.

ANS: A, C, E
Eliminating the conditions that created the problem will decrease the occurrences. The
skin should be cleaned with a mild soap or cleansing agent daily, and the skin should be
thoroughly dried. Lotion should not be used because it traps moisture. Antifungal
medications should be used 7 to 14 days or until the fungal infection is completely
cleared.

PTS: 1
Planning

DIF:

Understand

MSC: Physiological Integrity

REF: 188

TOP: Nursing Process: