Hair, Skin, and Nails Assessment PrepU

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?

"Do you feel anxious at times?"

A nurse is assessing a 49yo 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?

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

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?

"How has it changed?"

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 nail to regrow. What is the BEST response by the nurse?

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

A 35yo archaeologist comes to the office for a regular skin examination. She has just returned form her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client? a. age b. hair color c. actinic lentigines d. heavy sun exposure

a. age

A client tells the nurse about a raised lesion on the client's leg. What is the nurses fist nursing action? a. inspect the area b. ask further questions c. document the statement d. move on to next body system

a. inspect the area

Which of the following assessment findings most likely constitutes a secondary skin lesion? a. keloid formation at the site of an old incision b. facial acne c. facial lesions associated with herpes simplex d. psoriasis

a. keloid formation at the site of an old incision

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? a. psoriasis, fungal infections, trauma b. vitiligo, hirsutism, vitamin deficiency c. eczema, melanoma, herpes zoster d. alopecia, dermatitis, chemotherapy

a. psoriasis, fungal infections, trauma

The nurse is admitting a 79yo 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? a. the client may have been abused b. the client is elderly c. the client may have peripheral vascular disease d. the client may have a cognitive deficit

a. the client may have been abused

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?

existence of systemic diseases that have skin manifestations

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

Mrs. Anderson presents with an itchy raised rash that appears and disappears invidious locations. Each lesion lasts for many minutes. Which most likely accounts for this rash? a. insect bites b. urticaria or hives c. psoriasis d. purpura

b. urticaria or hives

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse knows this may be caused by what complication?

bacterial infection

The nurse is preparing to examine a client's skin. What would the nurse do NEXT? a. ensure that the room is hot to prevent chilling b. wear gloves when preparing to inspect the skin and nails c. expose only the body part that is being examined d. have the client remove clothing from the upper body

c. expose only the body part that is being examined

The nurse expects what change in a client's hair as a result of aging? a. an increase in the loss of fine, relatively unpigmented hair referred to as villus hair will occur b. the existing terminal hair will become coarser and less pigmented c. the amount of hair decreases d. eyebrows will thin and gradually disappear

c. the amount of hair decreases

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 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

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

increased thinness

The only layer of the skin that undergoes cell division is the:

innermost layer of the epidermis

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. the nurse knows the client needs medical follow-up for further assessment to rule out which condition?

iron deficiency anemia

Mrs. Hill is a 28yo women of African ancestry with a history of systemic lupus erythematous (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

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 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

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

wheal

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

papule

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?

patchy, thin hair

A 45yo African American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do NEXT?

perform a random blood sugar test

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described us caused by what?

peripheral cyanosis

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish, purple macules. the nurse should recognize the presence of:

petechiae

Which technique should the nurse use to properly assess a client's skin turgor?

pinch the skin over the clavicle and observe its return to the original shape

A client presents with possible lice infestation of the scalp. the nurse observes nits very close to the scalp. What does this finding tell the nurse?

the client had a recent infestation

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome?

- evaluate the client's outcomes - modify nursing interventions

Which situations should the nurse identify as being risk factors of the development of pressure sores?

- pressure that impairs capillary blood flow to the skin - friction created by dragging the skin against bedlinen - shearing that occurs when sliding down in bed - moisture being allowed to accumulate on the skin

Pressure ulcers are staged as I through IV. What is the progression of the stages?

1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. What are the ABCDEs?

A = asymmetry B = border irregularity C = color changes, especially blue D = diameter greater than 6mm E = evolution

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin:

D

An 8yo girl comes with her mother for evaluation of hair loss. The girl 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 mist likely diagnosis?

alopecia areata

Recommended protective measures to avoid skin cancer include:

avoiding sun exposure

Which statement by a client about the skin needs validation by the collection of objective data by the nurse? a. "I experience itchy and dry skin every winter." b. "My feet hurt and are always cold to the touch." c. "I had a small skin cancer removed about 3 years ago." d. "My port wine birth mark has not gotten any bigger."

b. "My feet hurt and are always cold to the touch."

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being MOST suggestive of melanoma? a. solid, dark brown color b. asymmetric, irregular borders c. diameter of 3mm d. flat with silvery scales

b. asymmetric, irregular borders

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 disorder? a. alopecia b. folliculitis c. ringworm d. tines capitis

b. folliculitis

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? a. the client has a full-time caregiver b. the client is consistently incontinent of urine c. the client has a surgical diagnosis d. the client adheres to a vegetarian diet

b. the client is consistently incontinent of urine

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 the scale? a. the client's current medication regimen b. the client's ability to change position c. the pigmentation of the client's skin d. the client's history of integumentary disorders

b. the client's ability to change position

A 14yo boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

consider admitting the client to the hospital

The nurse recognizes that which client is at greatest risk for the development of skin cancer? a. 28yo caucasian male who works in a paper mill b. 45yo female with 10 year history of cigarette smoking c. 15yo female with facial freckles d. 55yo male who lived in California for 20 years

d. 55yo male who lived in California for 20 years

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? a. cherry angioma b. cutaneous horn c. seborrheic keratosis d. pressure ulcer

d. pressure ulcer

A nurse is working with a 13yo 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

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the reposes on what physiological event that occurred as a result of the burn?

destruction of hair follicles located in the dermis layer

During an assessment the nurse performs the action shown in the image. What is the purpose of this action?

determine capillary refill

A 20yo 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

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of:

hypoxia

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

impetigo

A client is 20 weeks pregnant and has melanoma. What information can the nurse give the client about melanoma, when educating her about the effects of pregnancy?

melanoma generally resolves postpartum

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

oral mucosa

A client has a stage IV pressure ulcer on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyelitis

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

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

pustular acne

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematous. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority diagnosis for the client is:

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's:

sclera

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 resounds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

sebum production

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that:

squamous cell carcinomas are most common on body sites with heavy sun exposure

Connecting the skin to underlying structures is/are the:

subcutaneous tissue

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

under the breast