Honan Chapter 50: Nursing Assessment Integumentary Function

The school nurse is approached by a teenage student. The student says that she learned in science class that the outer layer of the skin is dead cells. The student wants to know which of her cells is going to die so they can be covered with skin. What would be the nurse's best response?

"All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called keratin cells."

A client is concerned about finding a few strands of hair on a pillow after sleeping and additional strands on the brush when styling the hair. Which response will the nurse make regarding the client's concern?

"There are approximately 100 strands of hair lost per day."

A patient has undergone testing in which a clinician has scraped a sample from the patient's skin lesion and fixed the sample to a slide. This patient most likely has which of the following integumentary health problems?

A fungal infection

The nurse has administered a subcutaneous injection of low-molecular-weight heparin to a patient who is recovering from surgery. This injection will be primarily deposited into:

Adipose tissue

Which of the following describes a total absence of pigment melanin?

Albinism

While performing perineal care for a female patient who has been recently admitted to the hospital, the nurse notes that the patient's pattern of pubic hair growth is more characteristic of a male's pattern of hair growth. The nurse should know that this could possibly be attributed to:

An endocrine disorder

Atrophy

Atrophy is a normal part of the aging process. Atrophy occurs when the epidermis becomes thin, dry, and transparent. Skin tends to become thinner as age progresses.

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client?

Avoidance of direct sunlight with protective clothing measures should be discussed with the client.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau line

A 29-year-old woman who gave birth to her first child yesterday had a particularly long labor but vaginally delivered a healthy infant. The nurse notes during this morning's assessment that the woman now has petechiae on her face. The nurse should understand that these lesions are a result of what process?

Broken blood capillaries

A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?

Calluses

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?

Conduction

When assessing pallor, the nurse understands that it is best observed on which of the following areas?

Conjunctivae

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis

A little boy is brought to the school nurse after falling off a swing. The nurse is documenting that the boy has bruising on the lateral aspect of his right arm. What term will the nurse use to describe bruising on the skin in documentation?

Ecchymoses

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.

Fingernails Hair Skin

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention

A patient's wife believes that a mole on her husband's forehead has been growing in recent weeks, though the patient himself denies this. What is the most accurate way for the nurse to gauge the suspected growth of this skin lesion?

Have photographs taken of the mole at regular intervals.

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster

Production of melanin is controlled by a hormone secreted by which of the following?

Hypothalamus

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

Hypoxia

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding?

It is a cherry angioma that is a normal age-related skin alteration.

Contact with a pathogen has precipitated a cutaneous immune reaction on a nurse's hands. The nurse would understand that this reaction primarily involves the action of what component of the integumentary system?

Langerhans cells

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification

Which of the following pigments influences hair color?

Melanin

Vitamin synthesis is among the many physiological processes that are performed by the integumentary system. Vitamin synthesis in the skin has the potential to reduce an individual's risk of what health problem?

Osteoporosis

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?

Petechiae

Petechiae

Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies.

A nurse who works with diverse populations is aware of the unique needs and challenges of individuals who live with skin diseases. Which of the following nursing diagnoses is commonly applicable to these individuals?

Risk for Disturbed Body Image

An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned about melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?

Senile lentigines

senile lentigines

Small, brown, pigmented, benign lesions, known as liver spots

senile keratoses

Small, yellow or brown, raised lesions

Tzanck smear

The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus.

The nursing student is learning about the elderly and the instructor is discussing physical changes associated with the aging process. What would the instructor tell the student about common changes in the skin associated with the aging process?

The elderly have skin atrophy.

The school nurse is assisting the teacher of a science class and a girl asks where the thickest part of the dermis is. What should the nurse answer?

The palms of the hands

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?

Vitiligo

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?

Yellowish waxy deposits on the eyelids

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?

clubbing

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?

macule