Ch. 14: Assessing Skin, Hair, and Nails

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? Psoriasis Pityriasis rosea Tinea infection Eczema

Psoriasis *This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

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

The client's perception affects the approach and effectiveness in treating the skin condition

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 wheals. vesicles. bullae. nodules.

vesicles *Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely? A malignant lesion An enlarged lymph node A sebaceous cyst An actinic keratosis

A sebaceous cyst *This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node and these do not usually drain to the skin.

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.) Yellow palms of the hands Age 55 years Actinic keratosis on face Light-colored hair Poor skin turgor

Age 55 years Light-colored hair Actinic keratosis on face *Risk factors for the development of skin cancer include age over 50, light-colored hair, and actinic keratosis on sun-exposed areas of the body. Poor skin turgor is not a risk factor for the development of skin cancer. Yellow palms of the hands are carotenemia, which is caused by a diet high in carrots and other yellow vegetables and fruits.

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

Avoiding sun exposure *While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

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. Circulates blood throughout the body Helps make vitamin D in the body Involved in digestion of food Largest organ of the body Aids in maintaining body temperature Protects against damage to the body from sunlight

Helps make vitamin D in the body Largest organ of the body Aids in maintaining body temperature Protects against damage to the body from sunlight *The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client? History of cigarette smoking Onset of iron deficiency anemia Environmental exposure to chemicals Treatment for fungal infections in the past

History of cigarette smoking *An increase in the angle between the nail base and the skin is seen in clients with clubbing, which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.

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 Contact dermatitis Psoriasis Seborrhea

Psoriasis *Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? Spooning Clubbing Beau's lines Paronychia

Spooning *Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document? Dermal Superficial Superficial-dermal Full thickness

Superficial *A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.

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? Multiple nevi Tinea corporis Herpes simplex Tinea versicolor

Tinea corporis *In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border asymmetry diameter great than 6 cm pink color

notched border asymmetry diameter great than 6 cm

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's nail beds. oral mucosa. palms. sclera.

oral mucosa. *Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. shearing that occurs when sliding down in bed 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 restlessly changing position frequently

shearing that occurs when sliding down in bed 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