Chapter 60: Assessment of Integumentary Function
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?
Dermis
During assessment of the integumentary system, the nurse notes patches of white skin on an African American man. The nurse knows that the lack of production of melanin could be related to a deficiency of a hormone from the:
Hypothalamus
Production of melanin is controlled by a hormone secreted by which gland?
Hypothalamus
Production of melanin is controlled by a hormone secreted by which of the following?
Hypothalamus
The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted?
Purple-gray cast
The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion?
Port-wine stains
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
Scale
A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas?
Sclerae
An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned that he has melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?
Senile lentigines
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?
The skin is ashen gray and dull.
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?
Yellowish waxy deposits on the eyelids
A client has an elevated temperature. The nurse is applying a cool compress to his forehead. This is an example of which of the following types of heat loss?
conduction
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?
conduction
Which type of heat loss is caused by a cool breeze that blows across the body surface?
convection
Which secondary skin lesions are associated with eczema?
crusts
What body structures have keratin as part of their composition?
All options are correct.
The nurse provides health teaching points to an adolescent about his skin. She reviews facts about hair growth and shaving. Which of the following sites has the slowest rate of growth?
Axillae
Which of the following causes odor in perspiration?
Bacteria on the skin
Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate?
Beard
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?
Beau's line
A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as:
Circumscribed and elevated masses >0.5 cm.
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
Clubbing
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?
Fluid retention
Which factor causes wrinkles among older adults?
Loss of subcutaneous tissue
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?
Make sure that the room is darkened.
Which of the following pigments influences hair color?
Melanin
To detect cyanosis in clients with dark skin, the nurse should assess which area?
Oral mucosa
The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?
Papule
The epidermis consists of four layers as listed below. Place the layers in the proper order from outermost to innermost.
Stratum corneum Stratum lucidium Stratum granulosum Stratum germinativum
Petechiae are associated with which of the following disorders?
Thrombocytopenia
Which diagnostic test is used to examine cells from herpes zoster?
Tzanck smear
Which of the following diagnostics is used to examine cells from herpes zoster?
Tzanck smear
The diagnosis of a skin disorder is made chiefly by which of the following?
Visual inspection
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?
Vitiligo
A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?
evaporation
When describing the layers of the skin to a group of nursing students, which of the following would the nursing instructor include as being a component of the dermis?
fibroblasts
The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as
fissure
The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?
keloid
The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?
keloid
Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?
macule
A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?
patch test
The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as
petechiae
A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum?
prevents drying and cracking of the skin and hair
During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.
vesicle
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?
vesicle
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?
vesicles
The nurse is caring for a client with herpes zoster. The nurse documents the lesions as
vesicles
Which term describes the transfer of heat from the body to a cooler object in contact with it?
Conduction
Nursing students are reviewing information about primary and secondary lesions. The students demonstrate understanding of the information when they identify which of the following as a primary lesion?
Wheal
Which term refers to yellowish waxy deposits on the upper and lower eyelids?
Xanthelasma
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?
"Have you been eating a large amount of carotene-rich foods?"
The nurse is teaching health promotion to a class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they identify that clients need how much sun exposure to synthesize sufficient vitamin D?
5 to 30 minutes twice a week
The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?
Biopsy
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?
Bronze
The nurse is assessing the skin of an older adult patient. Which of the following would the nurse identify as abnormal?
Bulla
The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding?
Hirsutism
After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?
Freckles
The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review?
Hemoglobin and hematocrit
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?
Herpes zoster
Which layer of the skin is made of primarily adipose tissue?
Hypodermis
During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding?
Iron deficiency anemia
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?
Jaundice
Which cells play a role in cutaneous immune system reactions?
Langerhans cells
Which type of cell is believed to play a significant role in cutaneous immune system reactions?
Langerhans cells
A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?
Lichenification
During assessment of a light-skinned patient, the nurse notices a yellow color present in the sclera of both eyes and the mucous membranes. The nurse knows that this finding could be associated with the presence of:
Liver dysfunction
While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following?
Liver spots
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?
Petechiae
Which condition is associated with bleeding tendencies or emboli to the skin?
Petechiae
When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?
Purplish cutaneous lesions
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
Pustule
An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition?
Reduction in sebum production
Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?
Spider angioma
The nurse is having difficulty seeing a client's rash. Which action(s) should the nurse perform to facilitate the assessment? Select all that apply.
Stretch the skin gently. Point a penlight laterally across the affected part.
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of
anemia
A nurse is examining a client's hair. What are the characteristics of a normal scalp? Select all that apply.
smooth intact free of lesions
Sudoriferous glands secrete which type of substance?
sweat