chapter 14 Assessing Skin, Hair, and Nails

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?

67-year-old White female

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

A nursing instructor is teaching nursing students the functions of the skin. Which of the following statements demonstrates students' understanding of the functions of the skin? Select all that apply.

It is the first line of defense." "It provides individual identity." The skin is the largest organ of the body." "It plays a vital role in temperature maintenance."

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

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

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

UV radiation exposure

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

Wood's light

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

distribution

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

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

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.

assymetrical change in size itching bleeding of a mole

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

Allow early identification of neurologic deficits

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

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

acne

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

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

distribution

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

folliculitis

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

hirsutism

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

vellus

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

A nurse is collecting a thorough 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

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

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 who is an active outdoor swimmer recently received a diagnosis of discoid systemic 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 effects of sunlight on skin lesions.

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

areola of the breast.

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

mascules

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

stage 2

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

stahe 2

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

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

BOTTOM

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

ashen

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?

do you feel anxious at time?

A client has a circumscribed, elevated, palpable mass containing serous fluid on the forearm. Which diagram should the nurse use to explain this mass to the client?

open buldge

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 2

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

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

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

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 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

subcutaneous tissue.

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

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

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

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

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

A neuropathic ulcer can develop without feeling it.