Chapter 14: Assessing Skin, Hair, and Nails

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment?

a cancerous skin lesion located on the back presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation

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"

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 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 23-year-old woman 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?

Small pits in the surfaces of the nails

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

Spooning

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

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

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

acne

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

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

blue

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

carotene

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.

When documenting that a client has freckles, the appropriate term to use is

macules

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules

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

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

wheal

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 • Largest organ of the body • Protects against damage to the body from sunlight • Aids in maintaining body temperature

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

palmar surfaces

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

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

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 friction protection

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

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The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

What is the rationale for asking the client whether he or she has noticed any new or changed moles?

Changes in existing moles or the appearance of new moles can indicate melanoma.

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

Destruction of hair follicles located in the dermis layer

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?

Document the findings in the client's record as normal

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

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

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?

Hematologic problem Coagulopathy Certain medications

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

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

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess?

Moisture Activity Nutrition

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?

Pustular acne

What is the most important focus area for the integumentary system?

UV radiation 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

Symptoms of stress

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

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 been abused.

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

Touch with the palmar surface of the three middle fingers.

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

areola of the breast.

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 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?

dermis

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

dermis

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

dermis

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

distribution

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

notched border diameter great than 6 mm asymmetry

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

oral mucosa

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 bed linen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

pulse oximetry

Connecting the skin to underlying structures is/are the

subcutaneous tissue

Which of the following is an important function of the skin?

synthesis of vitamin D

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

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

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarms

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

vellus