Assessment - Chapter 14 - Skin, Hair, and Nails

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? Exposure of subcutaneous tissue and muscle Ulceration resembling a crater Unbroken but red in color Broken with the presence of a blister

Broken with the presence of a blister

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Carotene Deoxyhemoglobin Melanin

Carotene

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? Macule Nodule Vesicle Papule

Macule

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Vertex Palmar surfaces Limbs Eyebrows

Palmar surfaces

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown? moderate high mild negligible

high

Connecting the skin to underlying structures is/are the... sebaceous glands. papillae. dermis layer. subcutaneous tissue.

subcutaneous tissue.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? a. Let the client remained fully dressed for the examination b. Have a nurse who is the same sex as the client examine him c. Allow the client to pray before the examination d. Avoid asking any questions regarding the client's lifestyle

Have a nurse who is the same sex as the client examine him

The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C?

Color

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Annular Linear Clustered Discrete

Clustered

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart? Eczema Seborrhea Psoriasis Contact dermatitis

Psoriasis

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? The client has COPD The client has melanoma The client has chronic hypoxia The client has asthma

The client has chronic hypoxia

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions? Tinea versicolor Tinea corporis Multiple nevi Herpes simplex

Tinea corporis

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is.. a) risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. b) dry flaking skin and dull dry hair as a result of disease. c) ineffective individual coping related to changes in appearance. d) anxiety related to loss of outdoor activities and altered skin appearance.

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash? Urticaria or hives Insect bites Purpura Psoriasis

Urticaria or hives

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion? Papsule Bullae Wheal

Wheal

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings? Eczema Psoriasis Tinea infection Pityriasis rosea

Psoriasis

Which of the following assessment findings most likely constitutes a secondary skin lesion? Facial lesions associated with herpes simplex Keloid formation at the site of an old incision

Keloid formation at the site of an old incision

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) a) Texture b) Other lesions on body c) Location d) Size e) Depth

a) c) d)

Why is it important for the nurse to ask the client what they think caused a skin condition? a) Doing so allows the client to decide what treatment is the best course of action b) The nurse can alleviate the client's fears about what caused the skin condition c) The client's perception affects the approach and effectiveness in treating the skin condition d) Doing so encourages the client to use home remedies to reduce medical cost

c)

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. a) necrosis with damage to underlying muscle b) ulceration involving the dermis c) intact, firm skin with redness d) full-thickness skin loss

c) b) d) a)

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are.. caused by aging of the skin in older adults. precancerous lesions. signs of an infectious process. signs of dermatitis.

caused by aging of the skin in older adults.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's... nodules. vesicles. bullae. wheals.

vesicles.

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse? a) Ask the client about any injury to the nails b) Report the finding to the health care provider c) Assess for adequate capillary refill time d) Document this as a normal finding

Document this as a normal finding

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as.. stage I. stage II. stage III. stage IV.

stage II.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Color Type Arrangement Distribution

Distribution

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyelitis

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears ashen. bluish. olive. greenish.

Ashen

Recommended protective measures to avoid skin cancer include which of the following? Seeking biannual examination by a clinician after age 40 years Avoiding sun exposure Performing monthly skin self-examinations Knowing signs of skin cancer

Avoiding sun exposure

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? Hypothyroidism Diabetes mellitus Crohns disease Cushing disease

Hypothyroidism

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. Largest organ of the body Aids in maintaining body temperature Protects against damage to the body from sunlight Circulates blood throughout the body Involved in digestion of food Helps make vitamin D in the body

Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin? Denies any skin color changes Skin warm and dry to the touch Small lesion left forearm for one month Dry and flaky skin in the winter months

Skin warm and dry to the touch

What is the most important focus area for the integumentary system? Washing the face and hands Moles with defined borders smaller than 6 mm Chemical exposure UV radiation exposure

UV radiation exposure

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of.. a great degree of cyanosis. hyperthyroidism. a mild degree of cyanosis. lupus erythematosus.

a great degree of cyanosis.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the.. soles of the feet. areola of the breast. adipose tissue. entire skin surface.

areola of the breast

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn? a) The impairment of apocrine gland to function effectively in the subcutaneous layer b) Destruction of hair follicles located in the dermis layer c) The ability of the adipose layer to produce carotene has been destroyed d) The damage to keratin producing cells in the epidermis layer

b)

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially... basal cell carcinoma. malignant melanoma. actinic keratoses. squamous cell carcinoma.

malignant melanoma.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as stage I. stage IV. stage II. stage III.

stage II.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Inspect the area Document the statement Move on to next body system Ask further questions

Inspect the area

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Flashlight Sunlight Artificial light Wood's light

Wood's light

Which of the following is an important function of the skin? Maintenance of acid-base balance Synthesis of vitamin D

Synthesis of vitamin D

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen moisture being allowed to accumulate on the skin shearing that occurs when sliding down in bed restlessly changing position frequently

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: symptoms of stress. pigmentation irregularities. allergies to certain foods. recent radiation therapy.

symptoms of stress.

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings? The client may have been abused. The client may have a cognitive deficit. The client may have peripheral vascular disease. The client is elderly.

The client may have been abused.

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy Psoriasis, fungal infections, trauma

Psoriasis, fungal infections, trauma

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client? Bullous impetigo Chickenpox Cystic acne Pustular acne

Pustular acne

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 55-year-old male who lived in California for 20 years 15-year-old female with facial freckles 45-year-old female with 10 year history of cigarette smoking

55-year-old male who lived in California for 20 years

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client? Age Hair color Actinic lentigines Heavy sun exposure

Age

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese? Anterior chest Under the breast Upper abdomen On the neck

Under the breast

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of... hypoparathyroidism. infectious conditions. hypothyroidism. hyperthyroidism.

hypothyroidism.

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? Macule Papule Vesicle Nodule

macule

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of... papules. macules. plaques. bulla.

macules