HAIR, SKIN, NAILS ASSESSMENT

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits

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

Beau lines in the nails are indicative of

a recent illness

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue

Which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility

A client with a zosteriform rash has a rash that

is distributed along a dermatome

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

Telangiectasia

skin lesion due to permanently enlarged and dilated blood vessels that are visible

This wound may also present as an intact or open/ruptured, serum-filled blister.

stage II pressure ulcer

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?

tinea corporis

spider angioma

A form of telangiectasis characterized by a central elevated red dot the size of a pinhead from which small blood vessels radiate

As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? Select all that apply.

Hematologic problem Certain medications Coagulopathy

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

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

How to assess skin turgor in a toddler diagnosed with pneumonia?

Pinch a fold of skin on the client's forearm.

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

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

dermis

sweat glands are located in which layer of skin?

dermis

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

distribution

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

squamous cell carncinomas are most common on body sites with

heavy sun exposure

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?

high

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

wheal

small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions

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

Which stage pressure ulcer has full-thickness tissue loss in which subcutaneous fat may be visible but bone, tendon, or muscle is not exposed?

stage III

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Color Location Distribution pattern Elevation

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

cherry angioma

a small, round, bright red blood vessel tumor on the skin, often on the trunk of the elderly

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

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

fainting (syncope)

The nails, located on the distal phalanges of the fingers and toes, are composed of

keratinized epidermal cells.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply

moisture activity nutrition

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 is caused by what?

peripheral cyanosis

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

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

pulse oximetry

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

Connecting the skin to underlying structures is/are the

subcutaneous tissue

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

vesicles