Chapter 9 The Integumentary System

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? 2 4 3 1

3 Explanation: 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.

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? Push the client toward the head of the bed to prevent back injury. Lower the head of bed and pull the client up with both arms. Place the client in Trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client.

Call for help and use the draw sheet to move the client. Explanation: Friction and shear forces are risk factors for developing pressure ulcers. The nurse should ask for help and use a draw sheet to avoid shearing forces. Pulling the client up in bed and allowing the client to slide in bed create friction and shear forces. Pushing the client also creates shearing forces.

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Deoxyhemoglobin Oxyhemoglobin Melanin Carotene

Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Connective layer Subcutaneous layer Epidermis Dermis

Dermis Explanation: The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

During an assessment the nurse performs the action shown in this image. What is the purpose of this action? Monitor oxygen status Assess finger range of motion Measure nerve function in the fingers Determine capillary refill

Determine capillary refill Explanation: This action is assessing for capillary refill which is done by pressing the nail tip briefly and watching for a color change. This action is not used to monitor oxygen status, assess finger range of motion, or to measure nerve function in the fingers.

Which of the following assessment findings most likely constitutes a secondary skin lesion? Psoriasis Facial lesions associated with herpes simplex Facial acne Keloid formation at the site of an old incision

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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. Protects against damage to the body from sunlight Involved in digestion of food Largest organ of the body Circulates blood throughout the body Helps make vitamin D in the body Aids in maintaining body temperature

Protects against damage to the body from sunlight Largest organ of the body Helps make vitamin D in the body Aids in maintaining body temperature Explanation: 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. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client is consistently incontinent of urine. The client has a surgical diagnosis. The client has a full-time caregiver. The client adheres to a vegetarian diet.

The client is consistently incontinent of urine. Explanation: The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? Angiomas Albinism Vitiligo Striae

Vitiligo Explanation: Vitiligo is characterized by discrete areas of depigmentation. Albinism is a generalized absence of pigment, and striae are often known as stretch marks. Angiomas are small, raised skin lesions.

Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. dermis. eccrine glands. keratinized tissue.

dermis. Explanation: 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 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis? Tinea versicolor Psoriasis Pityriasis rosea Atopic eczema

Pityriasis rosea Explanation: This is a classic description of pityriasis rosea. The description of a large single or "herald" patch preceding the eruption is a good way to distinguish this rash from other conditions.

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? Eczema Psoriasis Seborrhea Contact dermatitis

Psoriasis Explanation: 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 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? negligible moderate high mild

high Explanation: This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.

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 signs of an infectious process. caused by aging of the skin in older adults. signs of dermatitis. precancerous lesions.

caused by aging of the skin in older adults. Explanation: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

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: allergies to certain foods. symptoms of stress. recent radiation therapy. pigmentation irregularities.

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

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? "Does anyone else in your family have a rash like this?" "How painful is your rash?" "Are you allergic to foods, medications, or other substances?" "What have you been doing to control the itching?"

"Are you allergic to foods, medications, or other substances?" Explanation: The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information, such as a history of a previous or similar rash, pain, and measures taken to address the itching.

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? "What dietary supplements do you usually take?" "Do you take steroid medications on a regular basis?" "Has anyone in your family ever been diagnosed with skin cancer?" "Have you ever been assessed for diabetes?"

"Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

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? An actinic keratosis A sebaceous cyst An enlarged lymph node A malignant lesion

A sebaceous cyst Explanation: This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node and these do not usually drain to the skin.

A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response? Acne is caused by decreased activity of the sebaceous glands Acne is caused by the impedance of sebum secretion onto the skin's surface Acne is caused by the apocrine glands Acne is caused by enlarged apocrine glands

Acne is caused by the impedance of sebum secretion onto the skin's surface Explanation: As children approach puberty, the apocrine glands enlarge and become active. At puberty, sebaceous glands increase activity, resulting in large amounts of sebum secreted into the hair follicles of the face, neck, chest, and back. Anything impeding sebum secretion onto the skin's surface may result in the formation of closed comedones and ultimately acne.

The student nurse learns that examining the skin can do all of the following except? Identify physical abuse Reveal overhydration Allow early identification of neurologic deficits Allow early identification of potentially cancerous lesions

Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? Trichotillomania Traction alopecia Alopecia areata Tinea capitis

Alopecia areata Explanation: This is a typical description for alopecia areata. There are no risk factors for trichotillomania or traction alopecia. The physical examination is not consistent with tinea capitis, because the skin is intact.

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 Bleeding of a mole Flat Regular borders Change in size Itching

Asymmetrical, bleeding of mole, change in size, itching Explanation: Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin B12. C. D. A.

D. Explanation: The skin is the largest organ of the body. It 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.

Which clinical manifestation should the nurse expect to find in a client with edema? Prominent blood vessels Decreased skin mobility Mottled skin tones Decreased skin turgor

Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.

The nurse is preparing to examine a client's skin. What would the nurse do next? Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Ensure that the room is hot to prevent chilling. Have the client remove clothing from the upper body.

Expose only the body part that is being examined Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

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? Around the mouth and lips Fingers and toes Nose and earlobes Chest and abdomen

Fingers and toes Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.

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 Let the client remained fully dressed for the examination Avoid asking any questions regarding the client's lifestyle Allow the client to pray before the examination

Have a nurse who is the same sex as the client examine him Explanation: 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. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

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? Papule Macule Vesicle Nodule

Macule Explanation: A macule is a flat, non-palpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on it size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? Respiratory failure Hepatic failure Cardiovascular failure Renal failure

Renal failure Explanation: Uremic frost is a sign of marked renal failure. This appearance results from precipitation of renal urea and nitrogen waste products through sweat onto the skin. Uremic frost is not related to cardiovascular failure, hepatic failure, or respiratory failure.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous cells Sweat glands Sebum production Subcutaneous tissue

Sebum production Explanation: Sebum production decreases with age, increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? Stage IV Stage II Stage III Stage I

Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings? The client may have been abused. The client may have peripheral vascular disease. The client may have a cognitive deficit. The client is elderly.

The client may have been abused. Explanation: Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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 Insect bites Purpura Psoriasis

Urticaria or hives Explanation: 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 is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? When palpating lesions on the client's skin When palpating the client's hair When palpating the client's nail beds for texture and capillary refill When palpating the texture of the client's skin

When palpating lesions on the client's skin Explanation: Gloves are necessary when palpating any lesions because there is a risk of being exposed to drainage. Gloves are not normally necessary when palpating clients' nail beds, hair, or skin texture.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? The client's ability to change position The pigmentation of the client's skin The client's history of integumentary disorders The client's current medication regimen

The client's ability to change position Explanation: The Braden Scale appraises the client's level of mobility but does not directly include data related to medications, history of skin disorders, or pigmentation.

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 III. stage II. stage I. stage IV.

stage II Explanation: 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.

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Repeated sunburns in childhood may explain the presence of some of your moles. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Explanation: Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "I will report these to the health care provider so that medication can be prescribed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "It means you have skin cancer and need to have them removed." "These are considered a normal age-related change in the skin."

"These are considered a normal age-related change in the skin." Explanation: Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 13 11 9 15

15

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Cushing syndrome Marfan syndrome Alcoholism Parkinson's disease

Alcoholism Explanation: A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump).

Recommended protective measures to avoid skin cancer include which of the following? Avoiding sun exposure. Knowing signs of skin cancer. Performing monthly skin self-examinations. Seeking biannual examination by a clinician after age 40 years.

Avoiding sun exposure. Explanation: 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. Clinical examinations are recommended annually.

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? Unbroken but red in color Exposure of subcutaneous tissue and muscle Ulceration resembling a crater Broken with the presence of a blister

Broken with the presence of a blister Explanation: 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.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Lupus erythematosus Iron deficiency anemia Basal cell carcinoma Cushing's disease

Cushing's disease Explanation: Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

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 smooth Moist and rough Moist and smooth Dry and rough

Dry and rough Explanation: 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 notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? Infection A normal finding Hypoxia Vitamin C deficiency

Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Move on to next body system Ask further questions Document the statement Inspect the area

Inspect the area Explanation: 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.

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. palms. nail beds. sclera.

Oral mucosa Explanation: 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 would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Seborrheic keratosis Pressure ulcer Cutaneous horn Cherry angioma

Pressure ulcer Explanation: An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Psoriasis, fungal infections, trauma Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma Explanation: 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. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

Which of the following is an important function of the skin? Synthesis of vitamin D Maintenance of acid-base balance Protection against melanin deposits Production of carotene

Synthesis of vitamin D Explanation: A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.

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 asthma The client has melanoma The client has chronic hypoxia The client has COPD

The client has chronic hypoxia Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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? Multiple nevi Tinea corporis Tinea versicolor Herpes simplex

Tinea corporis Explanation: 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.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? Cardiopulmonary insufficiency Hyperglycemia Vasoconstriction Hypoxemia

Vasoconstriction Explanation: Peripheral cyanosis may be a local problem resulting from vasoconstriction. A cardiopulmonary etiology is unlikely in a client who enjoys overall good health.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the soles of the feet. areola of the breast. adipose tissue. entire skin surface.

areola of the breast. Explanation: 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.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of erosion. ulcers. scales. fissures.

fissures. Explanation: Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a patch. papule. plaque. macule.

papule. Explanation: Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.