Chapter 14

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

Helps make vitamin D in the body, protects against damage to the body from sunlight, aids in maintaining body temperature, largest organ of the body

A nurse inspects a client's nails and notes that 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 female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states, " I am so ugly with this rash!" Which diagnoses can the nurse confirm with this data?

Ineffective individual coping, anxiety, disturbed body image

the nails, located on the distal phalanges of the fingers and toes, are composed of

Keratinized epidermal cells

Which statement by the 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

A nurse is collecting a through and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?

Nail problems can be caused by an underlying systemic illness

Which technique should the nurse use to properly assess a client's skin tugor?

Pinch the skin over the clavicle and observe its return to the original shape.

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?

Psoriasis

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?

Skin warm and dry to the touch

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

Symmetrical shape

A nurse is interviewing a client regarding his personal health history to obtain subjective information to assist in her assessment of his skin. She asks him, "Have you has any recent hospitalizations or surgeries?" Which of the following is the best rationale for asking this question?

To determine the client's risk for acquiring a methicillin-resistant Staphyloccoccus aureus (MRSA) infection

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

Vitamin D

A nurse is preparing a client for a physical examination of his skin, hair and nails. Which of the following interventions should the nurse implement?

Wear gloves when palpating lesions, having the client remove his toupee, use sunlight if possible to inspect the skin, keep the room door closed.

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

Wood's light

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client?

age

While assessing an adult client's feet for fungal disease using a wood light, the nurse documents the presence of a fungus when the florescence is

blue

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

hypothyroidism

squamous cell carcinoma is associated with

overall amount of sun exposure

A client's skin color depends on melanin and carotene contained in the skin, and the

volume of blood circulating in the dermis

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

A 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

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?

A stage III ulcer

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process?

Diabetes mellitus

A nurse cares for a client with a stage 2 pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken, with the presence of a blister

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?

Change in size, bleeding of a mole, asymmetrical, itching

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

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

Which clinical manifestation should the nurse expect to find in a client with edema?

Decreased skin mobility

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 the skin?

Dermis

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

Document this as a normal finding

A nurse cared 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?

Documents the findings in the client's record as normal

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing

Domestic abuse

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

A nurse receives a report from the shift nurse that a client has new onset of peripheral cyanosis. The nurse recognizes that which of the following is the most likely underlying cause?

Local Vasoconstriction

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Location Distribution pattern Elevation Color

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

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

Melanin

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis?

Perioral

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that it has become difficult to cut his toenails because the nails have become hard and brittle. The client also states that his feet are always cold and he must wear socks to bed. Which nursing diagnosis can be confirmed from this data?

Risk for impaired skin integrity

The nurse assess 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 2

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 Corposis

A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you send long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question?

To determine the clients risk for pressure ulcers

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

Touch with the palmar surface of the three middle fingers

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

Tugor

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

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

The nurse is assessing a dark skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness

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

areola of the breast

To assess for anemia in a dark skinned client, the nurse should observe the client's skin for a color that appears

ashen

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

caused by aging of the skin in older adults

The nurse is assessing an African American clients skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to

chronic discoid lupus erythematosus

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis

A primary function of the hair in the nose and eyelashes is to serve as a

filter for dust

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

fissures

A female client visits the clinic and complains to the nurse that her skin feels "dry." the nurse should instruct the client that skin elasticity is required to adequate

fluid intake

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia

The only layer of the skin that undergoes cell division is the

innermost layer of the epidermis

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a

keloid

A client visits the clinic for a routine physical examination. The nurse prepares to asses the client's skin. The nurse asks the nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a generic component with skin cancer, especially

malignant melanoma

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

oral mucosa

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1cm. The nurse documents this as a

plaque

A client who is an active outdoor swimmer recently received a diagnosis of discoid system 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

risk for ineffective health maintenance related to deficient knowledge of effect of sunlight on skin lesions.

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

sclera

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

spoon nails

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

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

connecting the skin to underlying structures is/are the

subcutaneous tissue

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?

superficial

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

To assess an adult client's skin tugor, the nurse should

use two fingers to pinch the skin under the clavicle

Short, pale, and fine hair that is present over much of the body is termed

vellus

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

vesicles