Holistics Hair Nail and skin

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

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

emotional stress

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? Clubbing Spooning Beau's lines Paronychia

spooning

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Artificial light Wood's light Flashlight

wood light

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

Dermis

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

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Inspect the area Ask further questions Document the statement Move on to next body system

Inspect the area

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

caused by aging of the skin in older adults.

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

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

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

dermis

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? Anterior chest Upper abdomen On the neck Under the breast

Under the breast

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

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis

keloid formation at the site on old incision

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 melanoma skin cancers are the most common type of cancers. African Americans are the least susceptible to skin cancers. usually there are precursor lesions for basal cell carcinomas. squamous cell carcinomas are most common on body sites with heavy sun exposure.

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

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

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

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

subcutaneous tissue

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

vellus

The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as: vitiligo. erythema. pallor. tinea corporis.

vitiligo

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse? "I understand your concern, but this is a normal part of aging." "It sounds like you may have developed a deep vein thrombosis." "Have you ever told your health care provider this?" "It sounds like you have developed peripheral neuropathy."

"It sounds like you have developed peripheral neuropathy."

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

55-year-old male who lived in California for 20 years

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.

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? An enlarged lymph node A sebaceous cyst An actinic keratosis A malignant lesion

A sebaceous cyst

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

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? Allow the client to pray before the examination Let the client remained fully dressed for the examination Have a nurse who is the same sex as the client examine him Avoid asking any questions regarding the client's lifestyle

Have a nurse who is the same sex as the client examine him

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 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 grow back a finger nail

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 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 abdomen. Pinch a fold of skin on the client's cheek. Pinch a fold of skin on the client's upper thigh. Pinch a fold of skin on the client's forearm.

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

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

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin? Small lesion left forearm for one month Denies any skin color changes Skin warm and dry to the touch Dry and flaky skin in the winter months

Skin warm and dry to the touch

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin? Small lesion left forearm for one month Denies any skin color changes Skin warm and dry to the touch Dry and flaky skin in the winter months

Skin warm and dry to the touch

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

How should the nurse palpate the skin of a client to assess its texture? Touch with the palmar surface of the three middle fingers. Press the fingertips to the skin surface Rub the dorsal surface of the hand over the skin Pinch and roll the skin between the fingers

Touch with the palmar surface of the three middle fingers.

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

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. You Selected: intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

You Selected: intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

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.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had chemotherapy. radiation. a recent illness. steroid therapy.

a recent illness

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. entire skin surface. soles of the feet. adipose tissue.

areolas of the breast

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease? asking the client to blink rapidly before assessing the palpebral conjunctiva of the eye assessing the skin covering the client's elbow while applying moderate pressure asking the client to stick out the tongue and assess the presenting surface assessing the client's hard palate with a bright light

assessing the client's hard palate with a bright light

Recommended protective measures to avoid skin cancer include which of the following? Avoiding sun exposure Knowing signs of skin cancer Performing monthly skin self-examinations Seeking biannual examination by a clinician after age 40 years

avoiding sun exposure

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. red. yellow. purple.

blue

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? Newton scale Head-to-toe assessment Norton scale Braden scale

braden scale

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

carotene

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

fainting

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 ulcers. erosion. scales. fissures.

fissures

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate calcium. vitamin D. carbohydrates. fluid intake.

fluid intake

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body? palms of the hands face soles of the feet underarms

forearms

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 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 mild moderate negligible

high

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? Onset of iron deficiency anemia History of cigarette smoking Environmental exposure to chemicals Treatment for fungal infections in the past

history of cigarette smoking

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

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 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 Psoriasis Herpes zoster Viral Exanthem

impetigo

nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client? increased body and facial hair thick, yellow toenails dry patchy skin alopecia

increased body and facial hair

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

macules

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 basal cell carcinoma. actinic keratoses. squamous cell carcinoma. malignant melanoma.

malignant melanoma

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border diameter great than 6 mm asymmetry pink color

notched border diameter great than 6 mm asymmetry

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's nail beds. oral mucosa. sclera. palms.

oral mucosa

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 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? Eczema Pityriasis rosea Psoriasis Tinea infection

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? Cystic acne Pustular acne Bullous impetigo Chickenpox

pustular acne

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. 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 nursing diagnosis for the client is ineffective individual coping related to changes in appearance. anxiety related to loss of outdoor activities and altered skin appearance. dry flaking skin and dull dry hair as a result of disease. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

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

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

the amount of hair decreases

The nurse is admitting a 79-year-old 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? The client may have been abused. The client is elderly. The client may have peripheral vascular disease. The client may have a cognitive deficit.

the client may have been abused

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency? alopecia hirsutism tinea capitis trichotillomania

trichotillomania

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