Chapter 14 PrepU questions

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?

"How has it changed?" Ex:Asking an open-ended question will elicit a more complete response, such as how the mole has changed for example, diameter, color, shape). The other options will not elicit the information needed to direct next priority actions.

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. Ex: While all options are true of older adults' skin, it is most important to emphasize to a client with diabetes that a neuropathic ulcer can develop without the client feeling it. People with diabetes are more likely to experience decreased sensation in the feet. The slowing of the healing process that comes with aging is also exacerbated by diabetes, as circulation may be slowed and the rate in which nutrients are delivered to wounds becomes decreased. Therefore, to reduce the risk of client injury, the nurse should emphasize that the client with diabetes checks their feet on a regular basis.

The nurse is teaching a client about the use of sunscreen. What should the nurse include in the teaching? Select all that apply.

Apply sunscreen again every 2 hours while in the sun. Sunscreen should be applied again after sweating or swimming. Water-resistant sunscreen may be used during activities such as swimming. Regular use of sunscreen has been found to reduce the incidence of melanoma. Ex: The nurse should teach the client to use SPF 30, not SPF 20, sunscreen with broad-spectrum protection. Sunscreen should be applied again every 2 hours while in the sun. Sweating or swimming creates the need for sunscreen reapplication. Water-resistant sunscreen may be used during activities such as swimming. A landmark study in 2011 demonstrated that the regular use of sunscreen decreases the incidence of melanoma.

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

Avoiding sun exposure Ex: While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer.

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 Ex: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.

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

D Ex:It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

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 Ex: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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

Distribution Ex: The given terms denote anatomic location, or distribution, of skin lesions over the body.

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 Ex: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor.

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 Ex A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

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 Ex: Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown.

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 Ex: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate

The nurse in a clinic is caring for a 19-year-old male client who has a new onset of vesicles around the mouth and chin. The nurse completes an assessment, reviews data collected, and is determining which condition the client is experiencing.

Impetigo is a contagious superficial skin infection characterized by vesicles or bullae that eventually rupture and ooze serous fluid that forms the classic honey-colored crust.

The RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed Ex: Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area Ex: If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

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

Keloid formation at the site of an old incision Ex: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound.

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

Osteomyelitis Ex: This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible.

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 Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

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 Ex: Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions.

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 Ex: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

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 Ex: Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

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 Ex: Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.

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?

Stage 3 Ex: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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

Synthesis of vitamin D Ex: A vital role of the skin is the synthesis of vitamin D.

The nurse expects what change in a client's hair as a result of aging?

The amount of hair decreases Ex: The amount of hair is expected to decrease as a result of aging.

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 Ex: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees.

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply.

The dermis is the layer of skin below the epidermis. The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, blood vessels, lymph vessels, and nerve endings. It is also the origin of sebaceous glands, sweat glands, and hair follicles. Fat cells are contained in the subcutaneous tissue. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects the infant's skin.

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.

The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

A nursing instructor is teaching nursing students about hair. Which of the following statements represents the students' understanding of hair? Select all that apply.

There are different types of hair: vellus, which is like peach fuzz, found on most of the body; and terminal hair, which is found on the scalp and eyebrows. Gray or white hair is caused by a reduction in production (not total loss) of pigment. Vellus hair, not terminal hair, provides thermoregulation by wicking sweat away from the body. Nasal hair filters dust and other airborne debris.

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 Ex: In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

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

UV radiation exposure Ex: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma.

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 Ex: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

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

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

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

Wood's light Ex: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection.

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. Ex: Beau's lines occur after acute illness and eventually grow out.

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

areola of the breast. Ex: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

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. Ex: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

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

dermis Ex: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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?

hypoxia Ex: Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia.

A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?

increased body and facial hair Ex: Cushing's disease is caused by an increase level of sex hormones from the adrenal glands. The adrenal gland releases corticosteroids (cortisol), mineralocorticosteroids (aldosterone), and sex hormones. The increase in sex hormones causes increased facial, chest, and back hair growth and a deep voice in women (hirsutism).

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

innermost layer of the epidermis. Ex: The innermost layer of the epidermis (stratum germinativum) is the only layer that undergoes cell division and contains melanin (brown pigment) and keratin-forming cells.

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

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

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 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. Ex: Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

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 Ex: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority.

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. Ex: Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

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. Ex: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

Connecting the skin to underlying structures is/are the

subcutaneous tissue. Ex: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

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. Ex: Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?

trichotillomania Ex: Trichotillomania or compulsive hair pulling is associated with a psychiatric disorder. Alopecia is a term used to describe general hair loss, most often associated with male pattern baldness, or a loss of hair from medications such as chemotherapy. Hirsutism is the appearance of hair on the face of a female. Tinea capitis causes round areas of alopecia on the scalp of a person with a fungus infection.

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

vellus. Ex: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

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. Ex: Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.