Chapter 14: Assessing Skin, Hair, and Nails Prep U

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

fingers and toes

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

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

malignant melanoma

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

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

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

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

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

risk for impaired skin integrity

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

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

synthesis of vitamin D

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

the client exhibits no signs or symptoms of infection

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

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

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

vellus

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

wheal

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)

-location -size -texture

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

-notched border -diameter great than 6mm -asymmetry

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 tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

peripheral cyanosis

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?

Seborrheic keratosis

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

UV radiation exposure

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

-age 55 years -light colored hair -actinic keratosis on face

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? Select all that apply.

-asymmetrical -change in size -itching -bleeding of a mole

When inspecting the hair, what would the nurse note? (Select all that apply.)

-color -condition of hair shaft -hair shafts that are shiny

What does examination of the skin involve? Select all that apply.

-inspection -palpation

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

-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 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

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 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

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?

a sebaceous cyst

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease

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

allow early identification of neurologic deficits

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

ashen

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

avoiding sun exposure

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 nurse cares for a client with a stage II 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

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

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

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

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

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

distribution

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 clients 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

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

macules

The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing?

skin turgor

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

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

spooning

Connecting the skin to underlying structures is/are the

subcutaneous tissue