Health Assessment Chapter 14 Hair,skin, and nails

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm. Explanation: To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the patient's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

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 Explanation: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness. Explanation: Beau's lines occur after acute illness and eventually grow out.

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

dermis. Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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 Explanation: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years Explanation: The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red hair. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.

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

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

Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

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?

Clustered Explanation: In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.

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

Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.

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

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails Explanation: Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.

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 Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

Connecting the skin to underlying structures is/are the

subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch" Explanation: A nurse needs to validate any subjective information that either does not fit with the rest of the information supplied by the patient or any information that may indicate a problem exists. Cold feet that are painful need to be validated by careful assessment of the client's circulation. Dry and itchy skin is expected in the winter when the air is dry. Previous history of cancer and a port wine spot are past of the past medical history.

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

3 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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

Acne Explanation: Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex are vesicular lesions and psoriasis are plaque lesions.

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

Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

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

Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking Explanation: An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.

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

Peripheral cyanosis

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

areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

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. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

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 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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 Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral infection.

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 Explanation: In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

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

Touch with the palmar surface of the three middle fingers. Explanation: The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.

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

Dermis Explanation: The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

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 Explanation: The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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

-Inspection -Palpation Explanation: Examination of the skin involves inspection and palpation. It does not generally involve a nutrition assessment, percussion, or auscultation.

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

Braden scale Explanation: Identifying risk for skin breakdown is especially important in hospitalized or inactive patients. Many health care facilities use the Braden Scale to assess risk in patients, with interventions based on the total score.

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

Broken with the presence of a blister Explanation: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.

Squamous cell carcinoma is associated with

overall amount of sun exposure. Explanation: Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies Explanation: A serpiginous rash is snaking. This type of rash can be caused by scabies.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarms Explanation: The apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress. This type of gland does not secret on locations identified by the other options.

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. Explanation: Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

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?

Macule Explanation: A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

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. Explanation: Blue-green fluorescence indicates fungal infection.

When educating a patient about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)

-Red or light hair -Freckles -Immunosuppression Explanation: Risk factors for melanoma: history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sunexposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?

A sebaceous cyst Explanation: This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node and these do not usually drain to the skin.

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 Explanation: The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo Explanation: In vitiligo, depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment is normal skin color; the pale areas are vitiligo. The condition may be hereditary. These changes may be distressing to the patient.

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 Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.)

Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes Explanation: The skin provides a barrier protecting the body from injury caused by mechanical or chemical sources, penetration by microorganisms, and the loss of water and electrolytes. Regulation of body temperature is another function of the skin that allows heat to dissipate through sweat glands or permit heat storage through subcutaneous tissue. Synthesis of vitamin D is another function of the skin that occurs from cholesterol by the action of ultraviolet light. While the skin is a factor in both Vitamin D synthesis and in the regulation of body temperature neither are considered barrier functions of the skin.

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?

Psoriasis Explanation: Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

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 Explanation: Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric Explanation: Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial Explanation: A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.

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 Explanation: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

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. Explanation: Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia.