ch 14: integumentary

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

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.

discrete lesions

nevi

psoriasis

papules coalesced

acne lesion name

pustules - pus filled

The nurse should use which assessment tool to assess the client's risk for skin breakdown? Braden Scale Hendrich II VTE prophylaxis algorithm Morse Scale

Braden Scale The Braden Scale or Norton Scale, or another skin assessment tool should be used to assess for skin breakdown risk factors according to hospital standard protocol. The Hendrich II and Morse scale assess fall risk. Upon admission, clients are evaluated for venous thromboembolism (VTE) risk; but a separate skin assessment tool is used as well.

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests? (Tattoo) Burning when having an MRI Inaccurate results when having a leg X-ray Falsely elevated serum blood glucose levels Allergic response to dye when having a CT scan

Burning when having an MRI A risk involved with tattooing includes burning sensations when undergoing magnetic resonance imagining (MRI). Tattoos does not affect x-rays, blood glucose levels, or response to dye injected for a CT scan.

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

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing? (pinching clavicle) Carotid pulse Lymph nodes Skin turgor Intercostal spaces

Skin turgor Turgor refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched. Pinching the skin is not performed when assessing the carotid pulse, lymph nodes, or intercostal spaces.

Which of the following is an important function of the skin? Maintenance of acid-base balance Synthesis of vitamin D Protection against melanin deposits Production of carotene

Synthesis of vitamin D A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.

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 peripheral vascular disease. The client is elderly. The client may have been abused. The client may have a cognitive deficit.

The client may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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

asymmetry notched border diameter great than 6 mm

impetigo

bacterial skin infection characterized by bullae that rupture and ooze serous fluid

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea diaphoresis

fainting Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of scales. fissures. erosion. ulcers.

fissures Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

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. hypothyroidism. infectious conditions. hyperthyroidism.

hypothyroidism Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

fissures

linear cracks - athletes foot, cracked lips/hands

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. Moisture Activity Nutrition Age Admitting diagnosis

Moisture Activity Nutrition The Braden Scale is a simple effective tool that evaluates levels of risk for ulcer development in the client. With its high reliability, predictive validity, and ease of use, the Braden Scale can be used to assess clients as often as every shift if needed. Six factors are rated using a matrix scoring system: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Short, pale, and fine hair that is present over much of the body is termed vellus. terminal. dermal. lanugo.

vellus Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

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? Have a nurse who is the same sex as the client examine him Let the client remained fully dressed for the examination Avoid asking any questions regarding the client's lifestyle Allow the client to pray before the examination

Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse? "It sounds like you may have developed a deep vein thrombosis." "It sounds like you have developed peripheral neuropathy." "Have you ever told your health care provider this?" "I understand your concern, but this is a normal part of aging."

"It sounds like you have developed peripheral neuropathy." Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease. Decreased sensation may put the client at risk for developing pressure ulcers, impaired skin integrity, and skin infections. Although circulation does decrease as we age, peripheral neuropathy is not a normal part of aging. These signs and symptoms are not indicative of a deep vein thrombosis. Asking the client if they have told their health care provider is not the best response because it does not respond to the client's report.

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer? 80-year-old male of Native American/First Nations heritage 45-year-old male of African descent 18-year-old Latino female 67-year-old White female

67-year-old White female Fair-skinned people are at higher risk of developing skin cancer, especially those with light eyes and freckles and people who live far from the equator. However, high levels of sunlight exposure places all people at risk. Clients of African descent, Native American/First Nations heritage, Asians, and Latinos or Hispanics are generally darker-skinned people. Even though darker-skinned people are not as susceptible to skin cancers, they have a poorer prognosis because they are often diagnosed late.

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

Distribution The given terms denote anatomic location, or distribution, of skin lesions over the body.

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding? Suggest that the client use antiperspirant products Assess the client for changes in sensation due to vascular problems Document the findings in the client's record as normal Monitor the client for additional findings of cystic fibrosis

Document the findings in the client's record as normal Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating.

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? Raised, reddened, edematous papules or plaques, varying in size and shape Fluid-filled lesions greater than 1 cm in diameter Fluid-filled lesions less than 1 cm in diameter Purulent, fluid-filled, raised lesions of any size

Fluid-filled lesions less than 1 cm in diameter The rash of chicken pox is vesicles that are fluid-filled and less than 1 cm in diameter.

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. Helps make vitamin D in the body Involved in digestion of food Largest organ of the body Aids in maintaining body temperature Circulates blood throughout the body 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 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 Pustular acne Cystic acne Chickenpox

Pustular acne Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? varicella herpes zoster acne psoriasis

acne Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex are vesicular lesions and psoriasis are plaque lesions.

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that melanoma skin cancers are the most common type of cancers. usually there are precursor lesions for basal cell carcinomas. African Americans are the least susceptible to skin cancers. squamous cell carcinomas are most common on body sites with heavy sun exposure.

squamous cell carcinomas are most common on body sites with heavy sun exposure.

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. recent radiation therapy. pigmentation irregularities. allergies to certain foods.

symptoms of stress. Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

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 bullae. nodules. vesicles. wheals.

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.

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse? "Does nail biting run in your family?" "Have you been depressed lately?" "Have you always bitten your nails?" "Do you feel anxious at times?"

"Do you feel anxious at times?" Excessive nail biting may be a sign of anxiety. Although anxiety and depression can occur at the same time, nail biting is a sign of anxiety. While the nurse may want to find out if the nail biting is new, and while nail biting may run in the family, these are not the priority in this situation.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed? (stage 4 pressure ulcer) Osteoarthritis Osteomyelitis Osteopenia Osteoporosis

Osteomyelitis This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible. This ulcer does not increase the client's risk for developing osteopenia, osteoporosis, or osteoarthritis.

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

Subcutaneous tissue Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures. papillae connect epidermis to dermis

A nurse implements which skin assessment to determine the presence of dehydration in a client? Temperature Texture Thickness Turgor

Turgor Assessing for skin turgor will assist the nurse in determining the presence of dehydration. In dehydration, skin turgor will be decreased because the elasticity of the skin is diminished with less moisture. Temperature assesses circulation. Texture refers to smoothness or roughness. Skin is normally thin but can be increased with the presence of calluses or thin in client's with arterial insufficiency.

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. squamous cell carcinoma. malignant melanoma. actinic keratoses.

malignant melanoma. Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma.

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 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? Clustered Discrete Linear Annular

Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. 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.

The RN should intervene and further educate the nursing assistant when observing which action? Assisting feeding a client ground chicken with dentures in place Propping a client on the side using pillows under the hip, knees, and shoulder Independently pulling an immobile client up in bed Ambulating a client using a walker in the hallway

Independently pulling an immobile client up in bed Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.

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.) Size Texture Location Depth Other lesions on body

Size Location Texture A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or the depth of the lesion.

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? Small lesion left forearm for one month Dry and flaky skin in the winter months Skin warm and dry to the touch Denies any skin color changes

Skin warm and dry to the touch Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

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 melanoma The client has asthma The client has COPD The client has chronic hypoxia

The client has chronic hypoxia Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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? Insect bites Purpura Psoriasis Urticaria or hives

Urticaria or hives This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client? normal age-related changes in hair growth increased facial hair growth premature graying of hair patchy, thin hair

patchy, thin hair The thyroid gland controls metabolism. In hypothyroidism, the slowed metabolism decreases the rate of hair growth, resulting in thin patchy hair. This is more pronounced than typical age-related changes in hair. Hypothyroidism does not cause premature graying of hair. Increased facial hair is seen in Cushing's disease as a result of increased sex hormones from the adrenal gland (hirsutism).

The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as: tinea corporis. erythema. pallor. vitiligo.

vitiligo Vitiligo is characterized by areas of no pigmentation. Erythema is is redness from inflammation. Pallor is a generalized paleness in skin color often caused by anemia. Tinea corporis is characterized by a ring-like rash on the body.

A client's skin color depends on melanin and carotene contained in the skin, and the volume of blood circulating in the dermis. client's genetic background. number of lymph vessels near the dermis. vascularity of the apocrine glands.

volume of blood circulating in the dermis. The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1necrosis with damage to underlying muscle 4intact, firm skin with redness 2full-thickness skin loss 3ulceration involving the dermis

4intact, firm skin with redness 3ulceration involving the dermis 2full-thickness skin loss 1necrosis with damage to underlying muscle

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer

Dermis The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

What does examination of the skin involve? Select all that apply. Palpation Inspection Percussion Nutritional assessment Auscultation

Palpation Inspection Examination of the skin involves inspection and palpation. It does not generally involve a nutrition assessment, percussion, or auscultation.

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record? Primary Secondary Purpuric Vascular

Purpuric Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? The client changes position every 2 hours The client keeps the area clean and dry The client exhibits no signs or symptoms of infection The client knows prevention measures for pressure ulcers

The client exhibits no signs or symptoms of infection All options are appropriate outcomes for this client, but the most important outcome is that the client exhibits no signs or symptoms of infection since infection is a risk for additional injury.

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

UV radiation exposure Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

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? Under the breast Upper abdomen On the neck Anterior chest

Under the breast The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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

Wood's light The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

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

friction created by dragging the skin against bedlinen pressure that impairs capillary blood flow to the skin moisture being allowed to accumulate on the skin shearing that occurs when sliding down in bed Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position or is dragged rather than lifted up from a supine position, for example, the movements may distort the soft tissues of the buttocks and close off the arteries and arterioles. Friction and moisture further increase the risk. Changing position frequently will assist in preventing pressure sores.

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? negligible moderate mild high

high This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions? hypoxia iron deficiency anemia psoriasis fungal infection

hypoxia Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis.

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 sclera. nail beds. palms. oral mucosa.

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.

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 dry flaking skin and dull dry hair as a result of disease. ineffective individual coping related to changes in appearance. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. 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. Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse? "Do you know how to check for signs of skin cancer?" "How has it changed?" "Sometimes moles change as you age." "When did you notice the change?"

"How has it changed?" Asking an open-ended question will elicit a more complete response, such as how the mole has changed for example, diameter, color, shape). The other options will not elicit the information needed to direct next priority actions. Telling the client that moles change as we age is not an appropriate response; further assessment is needed. Asking if the client knows how to check for signs of skin cancer and about when they noticed the change are close-ended questions that will not provide the information needed.

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse? "It will grow back in time, but may never be the same." "It will only take about a week for it to fully regrow." "It takes about 6 months to totally replace a fingernail." "It will probably take about 12 months to totally replace a fingernail."

"It takes about 6 months to totally replace a fingernail." It takes 6 months to totally replace a fingernail and 12 months to totally replace a toenail. A week is too short for nail regrowth. Telling the client that the nail will never be the same is not providing accurate information or therapeutic communication.

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized? Wound healing becomes prolonged with age. Hydration alters skin turgor. A neuropathic ulcer can develop without feeling it. Skin collagen decreases with age.

A neuropathic ulcer can develop without feeling it. While all options are true of older adults' skin, it is most important to emphasize to a client with diabetes that a neuropathic ulcer can develop without the client feeling it. People with diabetes are more likely to experience decreased sensation in the feet. The slowing of the healing process that comes with aging is also exacerbated by diabetes, as circulation may be slowed and the rate in which nutrients are delivered to wounds becomes decreased. Therefore, to reduce the risk of client injury, the nurse should emphasize that the client with diabetes checks their feet on a regular basis.

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? Assists in keeping the skin intact Assists in friction protection Assists in keeping skin dry Assists in protection from infection

Assists in friction protection Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? Norton scale Head-to-toe assessment Newton scale Braden scale

Braden scale Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin? Stratum lucidum Stratum corneum Epidermis Dermis

Dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning? Existence of systemic diseases that have skin manifestations History of previous medical health promotion care Identifying the client's risk for developing skin cancer Minimizing the client's potential risk for pressure ulcer formation

Existence of systemic diseases that have skin manifestations One purpose of the integumentary health history is to identify systemic diseases that have skin manifestations. Questions to determine systemic diseases that the client may have include asking about prescribed medications, immunizations, and diagnosed illnesses. Such a history would provide little information regarding health promotion care, or risks for skin cancer or skin ulcer formation.

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? Onset of iron deficiency anemia Treatment for fungal infections in the past History of cigarette smoking Environmental exposure to chemicals

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.

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? Psoriasis Herpes zoster Viral Exanthem Impetigo

Impetigo Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthem is a macular or papular rash that is present along with a viral infection.

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

Inspect the area If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

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 Papule Vesicle

Macule A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor? Pinch a fold of skin on the client's cheek. Pinch a fold of skin on the client's forearm. Pinch a fold of skin on the client's upper thigh. Pinch a fold of skin on the client's abdomen.

Pinch a fold of skin on the client's forearm. To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the client's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

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 Tinea infection Eczema Pityriasis rosea

Psoriasis

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

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.

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 corporis Herpes simplex Tinea versicolor Multiple nevi

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.

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? The cyanosis may be a result of a prolonged period of exposure to the cold. The client's arterial blood will appear bluish when observed in the test tube. The client is demonstrating central cyanosis. The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood.

The cyanosis may be a result of a prolonged period of exposure to the cold. Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a response to anxiety or a cold environment. The bluish color of a subcutaneous vein is not the trigger for this form of cyanosis.

How should the nurse palpate the skin of a client to assess its texture? Touch with the palmar surface of the three middle fingers. Pinch and roll the skin between the fingers Rub the dorsal surface of the hand over the skin Press the fingertips to the skin surface

Touch with the palmar surface of the three middle fingers. The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? Papule Vesicle Wheal Cyst

Vesicle The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had steroid therapy. radiation. chemotherapy. a recent illness.

a recent illness. Beau's lines occur after acute illness and eventually grow out.

Herpes simplex vesicles along a dermatome vesicles in crops in various stages of healing clustered, fluid filled vesicles

clustered, fluid filled vesicles There are a variety of skin lesions that the nurse may be expected to assess. Herpes simplex lesions are fluid-filled vesicles that are clustered. They can develop around the mouth and chin. Vesicles along a dermatome are associated with herpes zoster. Vesicles that appear in crops in various stages of healing are associated with varicella. A cyst is a lesion that is walled off and contains either fluid or semi-solid material. Dry, scaly, shiny atrophic areas describe the skin of a person with peripheral vascular disease. Warm, moist, soft, velvety areas describes the skin of a person with hyperthyroidism. Impetigo is a contagious superficial skin infection characterized by vesicles or bullae that eventually rupture and ooze serous fluid that forms the classic honey-colored crust. An elevated palpable solid mass is associated with papules or plaques. Lesions with necrotic tissue loss are associated with an ulcer.

A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client? thick, yellow toenails alopecia dry patchy skin increased body and facial hair

increased body and facial hair Cushing's disease is caused by an increase level of sex hormones from the adrenal glands. The adrenal gland releases corticosteroids (cortisol), mineralocorticosteroids (aldosterone), and sex hormones. The increase in sex hormones causes increased facial, chest, and back hair growth and a deep voice in women (hirsutism). Thick, yellow nails would be a result of a fungal infection. Dry, patchy skin and alopecia are not symptoms of Cushing's disease.

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 II. stage IV. stage III. stage I.

stage II. Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

herpes zoster and varicella

vesicles - serous filled

clustered lesion

vesicles: herpes

A nurse performs a focused assessment on a client who has noticed changes in their nail beds. The nurse observes white color and separation of the nail plate from the nail bed. The nurse determines that these signs and symptoms indicate which of the following conditions? yeast infection fungal infection normal nail bed assessment bacterial infection

yeast infection. Yeast infections cause a white color and separation of the nail plate from the nail bed. Bacterial infections cause green, black, or brown nail discoloration. Yellow, thick, crumbling nails are seen in fungal infections. The nurse's findings are not normal for a nail assessment.