chapter 9 - the integumentary system PREP U

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? "Do you know how to check for signs of skin cancer?" "Sometimes moles change as you age." "When did you notice the change?" "How has it changed?"

"How has it changed?"

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question? "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." "SPF 15 is the number of minutes that a person can safely stay in the sun after treating the skin with the product." "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn.

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

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." "It means you have skin cancer and need to have them removed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."

"These are considered a normal age-related change in the 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. - Largest organ of the body - Involved in digestion of food - Protects against damage to the body from sunlight - Circulates blood throughout the body - Helps make vitamin D in the body - Aids in maintaining body temperature

- Largest organ of the body - Protects against damage to the body from sunlight - Helps make vitamin D in the body - Aids in maintaining body temperature

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse? "Does nail biting run in your family?" "Have you always bitten your nails?" "Have you been depressed lately?" "Do you feel anxious at times?"

"Do you feel anxious at times?"

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

Allow early identification of neurologic deficits

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Linear Annular Clustered Discrete

Clustered

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? Stratum corneum Stratum lucidum Dermis Epidermis

Dermis

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

Distribution

The nurse is performing a focused assessment on a 45-year-old client of African descent. The nurse observes the following: nail beds have pigmented streaks, 160-degree angle between the nail base and the skin. What action should the nurse take? Document the findings as normal. Request a prescription for bacterial infection. Place a consult for a nutritionist to address anemia. Notify the health care provider of abnormal findings.

Document the findings as normal.

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

Expose only the body part that is being examined.

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

Hypoxia

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color? Capillary blood flow Carotene Melanin Collagen

Melanin

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Nail beds Sclera Palms Oral mucosa

Oral mucosa

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

Pressure ulcer

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? Seborrhea Contact dermatitis Eczema Psoriasis

Psoriasis

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 Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? Stage I Stage II Stage III Stage IV

Stage II

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 The client has melanoma The client has COPD The client has asthma

The client has chronic hypoxia

A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following? Thick Thin Pale Flushed

Thin

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure

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. a mild degree of cyanosis. lupus erythematosus. hyperthyroidism.

a great degree of cyanosis.

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders? alopecia folliculitis ringworm tinea capitis

folliculitis

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client? normal age-related changes in hair growth increased facial hair growth premature graying of hair patchy, thin hair

patchy, thin hair

A client is diagnosed with paronychia. Which part of the nail should the nurse assess for this health problem?

proximal nail fold

Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.

vellus

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? -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." -"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."

-"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse? -"It will probably take about 12 months to totally replace a fingernail." -"It takes about 6 months to totally replace a fingernail." -"It will only take about a week for it to fully regrow." -"It will grow back in time, but may never be the same."

-"It takes about 6 months to totally replace a fingernail."

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. -Skin collagen decreases with age. -Wound healing becomes prolonged with age. -Hydration alters skin turgor

-A neuropathic ulcer can develop without feeling it.

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? -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. -Push the client toward the head of the bed to prevent back injury.

-Call for help and use the draw sheet to move the client.

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take? -Notify the health care provider. -Inform the client to stop chemotherapy. -Document findings. -Suggest the client shave their head.

-Document findings.

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning? -History of previous medical health promotion care -Identifying the client's risk for developing skin cancer -Minimizing the client's potential risk for pressure ulcer formation -Existence of systemic diseases that have skin manifestations

-Existence of systemic diseases that have skin manifestations

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. -It is likely to be related to an exposure to a chemical. -It is likely to be related to an allergic reaction. -It should not cause any problems.

-It is likely to be related to her lupus.

The nurse is performing a skin assessment on a client and notes the presence of a rash in a butterfly pattern across the bridge of the nose and cheeks. Which consideration should the nurse take into account based on this finding? -This is characteristic of systemic lupus erythematosus (SLE). -Poor hygiene may cause this type of rash. -Decreased melanin production due to aging may be a potential cause. -Yellowing of the sclera due to jaundice may also be present.

-This is characteristic of systemic lupus erythematosus (SLE).

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply. -Ask the client to remove only his shirt -Have the client stand for the entire examination -Use sunlight, if possible, to inspect the skin -Have the client remove his toupee -Wear gloves when palpating lesions -Keep the room door closed

-Use sunlight, if possible, to inspect the skin -Have the client remove his toupee -Wear gloves when palpating lesions -Keep the room door closed

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 dermic -full-thickness skin loss -necrosis with damage to underlying muscle

To assess an adult client's skin turgor, the nurse should -press down on the skin of the feet. -use the dorsal surfaces of the hands on the client's arms. -use the finger pads to palpate the skin at the sternum. -use two fingers to pinch the skin under the clavicle.

-use two fingers to pinch the skin under the clavicle.

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore? 9 or lower 10 to 12 13 to 18 19 to 23

19 to 23

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? 1 2 3 4

3.

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer? 67-year-old White female 18-year-old Latino female 45-year-old male of African descent 80-year-old male of Native American/First Nations heritage

67-year-old White female

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? Alopecia areata Trichotillomania Tinea capitis Traction alopecia

Alopecia areata

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 Flat Change in size Itching Bleeding of a mole Regular borders

Asymmetrical Change in size Itching Bleeding of a mole

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? Integumentary Digestive Neurologic Circulatory

Circulatory

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? Moist and smooth Moist and rough Dry and smooth Dry and rough

Dry and rough

The apocrine glands are stimulated by what? Emotional stress Temperature Physical stress Overhydration

Emotional stress

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? Continuous trauma Excessive collagen formation Decreased subcutaneous tissue Inadequate circulation

Excessive collagen formation

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? Diabetes mellitus Hypothyroidism Crohns disease Cushing disease

Hypothyroidism

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? Nodule Papule Vesicle Macule

Macule

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

Osteomyelitis

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 Cardiovascular failure Hepatic failure Respiratory failure

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? Squamous cells Sweat glands Subcutaneous tissue Sebum production

Sebum production

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 versicolor Herpes simplex Tinea corporis

Tinea corporis

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? Vitiligo Striae Angiomas Albinism

Vitiligo

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion? Wheal Papule Pustule Erosion

Wheal

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

dermis.

A nurse observes yellow, thick, crumbling toenails on a new client. The nurse suspects which of the following conditions? bacterial infection fungal infection yeast infection local irritation

fungal infection

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. hyperthyroidism. infectious conditions. hypoparathyroidism.

hypothyroidism.

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? iron deficiency anemia fungal infection psoriasis hypoxia

hypoxia

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of macules. papules. plaques. bulla.

macules

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 plaque. macule. papule. patch.

papule

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 I. stage II. stage III. stage IV.

stage II.

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 I. stage II. stage III. stage IV.

stage II.

Connecting the skin to underlying structures is/are the papillae. sebaceous glands. dermis layer. subcutaneous tissue.

subcutaneous tissue.

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. recent radiation therapy. pigmentation irregularities. allergies to certain foods.

symptoms of stress.

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 nodules. bullae. vesicles. wheals.

vesicles