Chapter 11: Skin, hair, and nails

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch"

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

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

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?

Acute illness

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

Consider admitting the client to the hospital.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D

How should the nurse palpate the skin of a client to assess its texture?

How should the nurse palpate the skin of a client to assess its texture?

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

Monthly

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

The client is consistently incontinent of urine.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days

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

Vesicle

A client with a family history of keloids asks the nurse, "What are common causes of keloids?" What should the nurse include in the response?

ear piercing surgical scarring

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?

high

Which situations should the nurse identify as being risk factors of the development of pressure sores?

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

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?

19 to 23

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease?

Asymmetrical Change in size Itching Bleeding of a mole

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

Can be caused by an underlying systemic illness

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

Circulatory

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?

Excessive collagen formation

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

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

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

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?

Impetigo

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?

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 has sustained burns over 50% of the body. When planning care for this client, the nurse will include interventions to address which alteration in the skin's barrier function?

Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Oral mucosa

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Skin that feels boggy on palpation

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum

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 chronic hypoxia

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

There is a non-blanching reddened area on the client's coccyx region.

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

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

Vesicle

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast.

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

assessing the client's hard palate with a bright light

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

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

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

The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

papule

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?

patchy, thin hair

The nurse is assessing a client exhibiting round, red and purple macules that are approximately 1 to 2 mm in size. The nurse should document which type of vascular skin lesion?

petechiae

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 II

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries