Chapter 60: Assessment of Integumentary Function

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 cooling overwarm skin trapping debris in the external ear contributing to acidity of perspiration to decrease microbial growth

1

A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas? Sclerae Mucous membranes Nail beds Ear lobes

1

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 Pallor Bronzed appearance Cherry red face

1

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? Freckles Dryness Itchy spots Yellowish waxy deposits

1

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 Reduction in the elasticity of the skin Reduction in melanin production Reduction in estrogen production

1

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 Patch Papule Plaque

1

Petechiae are associated with which of the following disorders? Thrombocytopenia Deep vein thrombosis Pulmonary emboli Acute respiratory distress syndrome (ARDS)

1

Sudoriferous glands secrete which type of substance? Sweat Oil Hormones Cerumen

1

The nurse documents the skin color change of a dark-skinned African American patient in cardiogenic shock as: Ashen gray and dull. Dusky blue. Reddish pink. Whitish pink.

1

The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of? Psoriasis Vitiligo Diabetes Melanoma

1

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as vesicles. wheals. pustules. cysts.

1

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 Ecchymoses Cherry angiomas Telangiectasias

1

Which cells play a role in cutaneous immune system reactions? Langerhans' cells Merkel cells Melanocytes T-lymphocytes

1

Which is the principal hardening ingredient of the hair and nails? Keratin Melanin Merkel cells Sebaceous gland

1

Which of the following actions helps the nurse to determine the quality of the skin turgor? Grasping the skin Inspecting the palmar surface Placing the dorsum of the hand on the surface of the skin Palpating the skin

1

Which of the following diagnostics is used to examine cells from herpes zoster? Tzanck smear Skin scrapings Patch testing Skin biopsy

1

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? Vitiligo Hirsutism Lichenification Telangiectases

1

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 Dark discoloration of the skin Bright red moles Hypertrophied scar tissue

1

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. Fingernails Hair Skin Endocrine glands Subcutaneous tissue

1,2,3

Which of the following is a strong positive reaction to patch testing? Select all that apply. Blisters Pain Ulceration Redness Itching

1,2,3

A nurse is assessing a patient with impetigo. The nurse would most likely observe which of the following? Wheal Pustule Vesicle Papule

2

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely? Skin biopsy Patch testing Tzanck smear Wood's light examination

2

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? Anemia Hypoxia Local trauma Psoriasis

2

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? Epidermis Dermis Papillary layer Stratum corneum

2

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? Sebum deficiency Fluid retention Dehydration Protein deficiency

2

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? Splinter hemorrhage Beau's line Paronychia Clubbing

2

Production of melanin is controlled by a hormone secreted by which gland? Thyroid Hypothalamus Adrenal Parathyroid

2

The diagnosis of a skin disorder is made chiefly by which of the following? Palpation Visual inspection Biopsy Culture

2

The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing? Anemia Carbon monoxide poisoning Polycythemia Shock

2

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? Vitiligo Psoriasis Melanoma Petechia

2

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? Fungal infection Herpes zoster Psoriasis Seborrheic dermatosis

2

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? Melanocytes Fibroblasts Keratin Adipose tissue

2

Which factor causes wrinkles among older adults? Decrease in melanin Loss of subcutaneous tissue Decrease in estrogen production Decrease in sebum

2

Which term describes the transfer of heat from the body to a cooler object in contact with it? Radiation Conduction Lichenification Evaporation

2

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? Macule Vesicle Pustule Cyst

3

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? Radiation Evaporation Conduction Convection

3

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of albinism. vitiligo. anemia. local arterial insufficiency.

3

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 ingesting large quantities of alcohol?" "Have you been diagnosed with Addison's disease?" "Have you been in the sun a lot?" "Have you been eating a large amount of carotene-rich foods?"

4

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? Skin biopsy Skin scrapings Tzanck smear Patch test

4

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? Erosion Pustule Cyst Spider angioma

4

The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as scale. erosion. ulcer. fissure.

4

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? Concave Brittle Discolored Clubbing

4

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? Flat with skin color change Circumscribed border Greater than 1 cm in diameter Elevated and palpable

4

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? Liver spots Dark discoloration of the skin Bright red moles Yellowish waxy deposits on the eyelids

4

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? Atrophy Scar Lichenification Keloid

4

Which of the following could be a possible cause of cyanosis? Carbon monoxide poisoning Fever Anemia Low tissue oxygenation

4

Which of the following pigments influences hair color? Pheromones Keratin Sebum Melanin

4

Which term refers to yellowish waxy deposits on the upper and lower eyelids? Dyschromia Xerosis Neurodermatitis Xanthelasma

4

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is a symptom of what? Jaundice Sjorgen's syndrome Addison's disease Vitiligo

4