Chapter 9: The integumentary System Prep U

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

"These are considered a normal age-related change in the skin."

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

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

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

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?

Renal 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?

Sebum production

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?

Skin tags are common benign skin lesions

A decrease in oxyhemoglobin will result in documentation of pallor.

True

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

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

dermis

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

macules

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

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?

Are you allergic to foods, medications, or other substances?

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?

Cushing's disease

When the nurse is inspecting a client's fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer?

Dermal

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

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

Dermis

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 nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined.

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

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?

Hypoxia

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 II

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure Ulcer

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

Vesicle

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

Carotene

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

fissures

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

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

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

Acne

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

Independently pulling an immobile client up in bed

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?

It is likely to be related to her lupus

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

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

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 nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis.

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 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?

"Do you take steroid medications on a regular basis?"

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?

Chronic Hypoxia