Chapter 11: Skin, Hair, and Nails Assessment- 311

The student nurse learns that examining the skin can do all of the following except? A. Reveal overhydration B. Allow early identification of neurologic deficits C. Identify physical abuse D. Allow early identification of potentially cancerous lesions

Allow early identification of neurologic deficits

A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Pus on the skin

A client with a family history of melanoma wants to have specific body moles assessed. In order to perform this assessment effectively, the nurse should have access to what equipment? Select all that apply. A. Warm water B. Ruler C. Gloves D. Magnifying glass E. Natural lighting

Ruler, Gloves, natural lighting

A 23-year-old women has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? A. Transverse white lines in the nails B. Beau's lines C. White spots, or leukonychia, on the nail surfaces D. Small pits in the surfaces of the nails

Small pits in the surfaces of the nails

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? A. The client has chronic hypoxia B. The client has melanoma C. The client has COPD D. The client has asthma

The client has chronic hypoxia

To assess an adult client's skin turgor, the nurse should A. Press down on the skin of the feet B. Use the dorsal surfaces of the hands on the client's arms C. Use the finger pads to palpate the skin at the sternum D. Use two finger pinch the skin under the clavicle

Use two finger pinch the skin under the clavicle

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

Wood's light

A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Hole goes down to the fat layer

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? A. When palpating the texture of the client's skin B. When palpating the client's hair C. When palpating lesions on the client's skin D. When palpating the client's nail beds for texture and capillary refill

When palpating lesions on the client's skin

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? A. "Are you allergic to foods, medications, or other substances?" B. "Does anyone else in your family have a rash like this?" C. "How painful is your rash?" D. "What have you been doing to control the itching?"

"Are you allergic to foods, medications, or other substances?"

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? A. "Does nail biting run in your family?" B. " Have you always bitten your nails?" C. "Have you been depressed lately?" D. "Do you feel anxious at times?"

"Do you feel anxious at times?"

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? A. Acne B. Psoriasis C. Varicella D. Herpes simplex

Acne

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 A. Signs of an infectious process B. Caused by aging of the skin in older adults C. Precancerous lesions D. Signs of dermatitis

Caused by aging of the skin in older adults

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin? A. Dermis B. Adipose C. Epidermis D. Subcutaneous

Dermis

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? A. Continuous trauma B. Excessive collagen formation C. Decreased subcutaneous tissue D. Inadequate circulation

Excessive collagen formation

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? A. Iron deficiency anemia B. Fungal infection C. Psoriasis D. Hypoxia

Hypoxia

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy? A. Melasma generally resolves postpartum B. Melasma is always permanent C. Melasma can be treated with Betadine ointment D. Melasma should be treated with antibiotics

Melasma generally resolves postpartum

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? A. Squamous cells B. Sweat glands C. Subcutaneous tissues D. Sebum production

Sebum production

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 A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Stage 2

The nurse is performing a skin assessment on a client and notes the presence of a rash in a butterfly pattern across the bridge of the nose and cheeks. Which consideration should the nurse take into account based on this finding? A. This is characteristic of systemic lupus erythematosus (SLE) B. Poor hygiene may cause this type of rash C. Decreased melanin production due to aging may be a potential cause D. Yellowing of the sclera due to jaundice may also be present

This is characteristic of systemic lupus erythematosus (SLE)