Health assessment chapter 11

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

Allow early identification of neurologic deficits

A client ask a nurse to look at a raised lesion on the skin that has been present for five years. Which is in " ABCDE" terroristic of malignant melanoma

Asymmetrical shape

A nurse cares for a client with a stage two pressure ulcer on the right hip. The nurse anticipates finding what type of adherence to the skin over this area?

Broken with the presence of a blister

The nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment of this client for fundings associated with which disease process ?

Crushing's disease

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

D

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

Distribution

A nurse performs a focused assessment on a new client. The nurse observes that the clients 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?

The nurse is preparing to examine a client skin. What would the nurse do Next?

Expose only the body part that is being examined.

A nurse reviews report from the Shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focused assessment on the skin to detect the presence of this condition?

Fingers and toes

A nurse performs a focus assessment on a new client. The nurse observes pustules and erythema around the clients hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorder?

Folliculitis

A client who is bedfast response only to painful stimuli, never ate a complete meal, and moves occasionally in bed. Which term so the nurse use to describe this clients risk for skin break?

High

While performing a focused skin assessment on a new client, The client reports, " The mall on my neck seems different." What is the best response about the nurse?

How has it changed?

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

Hypoxia

What does examination of the skin involve? Select all that apply

Inspection palpation

When documenting that a client has freckles, The appropriate term to use is?

Macules

Which situation to the nurse identify as being risk factors of the development of pressure sores? Select all that apply 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 changing position frequently

Pressure that impairs capillary blood flow to the skin correction created by dragging the skin against bed linen Sharing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

A nurse assesses a client for past history of no problem. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

Client presents to the healthcare clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to touch

Which of the following findings realtors your hair what the nurse most likely says in an older adult female client

Terminal hair grows on chin

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

Under the breast

A nurse is implementing appropriate infection control precautions while performing a client skin assessment. The nurse would wear gloves during which part of the assessment?

When populating lesions on the client skin

A client asked a nurse to look at a raised lesion on The skin that has been present for about five years. Which is an, " ABCDE" characteristic of malignant melanoma?

Asymmetrical shape

A nurse is working with a 13-year-old boy who complains that he has began to sweat a lot more than he used to. He ask the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

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

Dermis

A client recovering from a burn injury is told by the healthcare provider that hair will no longer grow in the body part that was burned. When the client questions why this is true, The nurse for baster response on the physiological event that occurred as a result of the burn?

Destruction of hair follicles located in the dermis layer.

The nurse is assessing a middle-age female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the clients ethnicity l. What assessment questions should the nurse ask?

Do you take steroid medication's on a regular basis?

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for a valuation of fatigue, Weight gain, and hair loss. The previous clinician had a strong suspicion is that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client was Hypothyroidism?

Dry and rough

A client has a seven MM lesion was irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

A nurse is collecting a thorough and accurate subjective history of a clients nail problems. The client asked why this is necessary. What does the following should the nurse mention in response?

No problems can be caused by an underlying systemic illness

While inspecting the skin of an older client, The nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Petechiae

A client asks, " what does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base response to the clients question?

SPF 15 is the radio of the number of minutes for a treated versus untreated skin to redden with exposure to to ultraviolet b rays

an older adult female client is concerned because her skin is very dry. she asked 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 the decrease of what?

Sebum production

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

Stage II

An eight year old girl comes with her mother for evaluation of hair loss. The girls and I was pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughters hair in braids. Physical examination reveals a clearly demarcated, Brown 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