Chapter 11 - Skin, Hair, and Nails Assessment

A 63-year-old patient hospitalized with pancreatitis is having problems performing ADLs. The nurse's aide brushes the patient's hair and tells the nurse that the patient is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse? A) Abnormal endocrine function B) Abnormal ovarian function C) Abnormal hepatic function D) Abnormal integumentary function

A) Abnormal endocrine function

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the patient's hairline. What would this indicate to the nurse? A) Renal failure B) Cardiovascular failure C) Hepatic failure D) Respiratory failure

A) Renal failure

The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient? A) The patient exhibits no signs or symptoms of infection B) The patient changes position every 2 hours

A) The patient exhibits no signs or symptoms of infection

When inspecting the hair, what would the nurse note? (Select all that apply.) A) Color B) Condition of hair shaft C) Length of hair D) Hair breakage of more than 6 hairs E) Hair shafts that are shiny

A, B, E

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) A) Lymphatic vessels B) Connective tissue C) Vernix D) Blood vessels E) Sweat glands

A, D, E

An 81-year-old man presents at the clinic with a painful ulcer on the left big toe. The patient states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect? A) Infected spider bite B) Arterial ulcer C) Infected tick bite D) Venous ulcer

B) Arterial ulcer

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

B) Assists in friction protection

An obese 34-year-old man is undergoing a preoperative examination prior to having bariatric surgery. The patient tells the nurse that he has a red sore in his groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect? A) Roseola B) Candida C) Pityriasis rosea D) Herpes simplex

B) Candida

A 17-year-old Hispanic teen comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the patient also reports that hair is growing on her upper inner thighs. What would the nurse suspect? A)Endocrine disorder C) Hepatic dysfunction B) Ovarian dysfunction D) Chronic nephrosis

B) Ovarian dysfunction

The nurse in the dermatology clinic is assessing a 39-year-old woman who has presented at the clinic with a lesion on her left inner thigh. The patient tells the nurse that she discovered the lesion one month ago and has noticed no changes in the color or size of the lesion. What would be the most appropriate teaching subject for this patient? A) Skin self-examination B) Signs and symptoms of melanoma C) Recognizing different types of lesions D) Protection from sun damage

B) Signs and symptoms of melanoma

The nurse is performing a generalized assessment of a 79-year-old man who has come to the clinic for his annual physical examination. The nurse notes that the patient's skin is thin and rough with abrasions. The patient tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger." When asked if he has any other problems, the patient says that he always seems to be cold. How would the nurse note these findings in the patient's medical record? A) The patient has abnormal thinning of skin B) The patient's integumentary system is within normal limits C) The patient states that wounds are taking longer to heal D) The patient has an abnormal inability to maintain temperature

B) The patient's integumentary system is within normal limits

As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? (Select all that apply.) A) Osteomyelitis B) A hematologic problem C) Certain infections D) Inappropriate play companions E) A coagulopathy

B, C, E

An 84-year-old woman is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the patient's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) A) Depth B) Location C) Other lesions on body D) Size E) Texture

B, D, E

A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response? A) "Take the baby to the emergency room to be evaluated." B) "Bring your baby to the clinic immediately." C) "This may be normal in infants." D) "This is a sign of a nutritional deficiency. What are you feeding your infant?"

C) "This may be normal in infants."

A woman and her 14-year-old boy have come to the clinic. The boy has acne lesions and says that he cannot control them. The mother asks the nurse what causes acne. What would be the nurse's best response? A) Acne is caused by the apocrine glands B) Acne is caused by decreased activity of the sebaceous glands C) Acne is caused by the impedance of sebum secretion onto the skin's surface D) Acne is caused by enlarged epocrine glands

C) Acne is caused by the impedance of sebum secretion onto the skin's surface

A 6-year-old girl is brought to the pediatric clinic by her mother, who tells the APRN that her daughter has a sore on her leg that "just keeps getting bigger." On examination, the APRN notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the APRN tell the mother the lesion is? A) Varicella B) Scabies C) Impetigo D) Rubella

C) Impetigo

A patient has been prescribed tetracycline for acne. What is the most important point the nurse should make in patient teaching about this medication? A) The patient may experience phototoxicity B) The medication may interfere with the menstrual cycle C) The patient may experience photosensitivity D) The medication may be inactivated by antacids

C) The patient may experience photosensitivity

A pediatric nurse is doing her initial shift assessments on assigned patients. One of the patient's is a toddler with pneumonia. How would the nurse assess this patient's skin turgor? A) Pinch a fold of skin on the patient's abdomen B) Pinch a fold of skin on the patient's cheek C) Pinch a fold of skin on the patient's upper thigh D) Pinch a fold of skin on the patient's forearm

D) Pinch a fold of skin on the patient's forearm

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

D) Psoriasis

A newborn has a hemangioma on the face. What would be important for the nurse to include in patient teaching? A) Will need surgery to remove B) Will become smaller over the first year of life C) Is made of epithelial cells that form caverns and fill with blood D) Will usually resolve by age 9 years

D) Will usually resolve by age 9 years