Integumentary PrepU Health Assessment

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

Cushing's disease

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

D

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

There is a nonblanching reddened area on the client's coccyx region.

an elderly vietnamese client is having his skin assessed. the nurse notes multiple bruises and abrasions on his legs. what practice by southeast asian people could this be the result of?

coining

the nurse is using the mnemonic ABCDE to assess a client's mole. what should the nurse document for the C?

color

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

distribution

a nurse cares for a client of Asian descent and noticed that the client swears very little and produces no body odor. what is an appropriate action by the nurse in regards to this finding?

document the findings in the client's record as normal

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?

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

a client tells the nurse about a raised lesion in the client's leg. what is the nurse's first nursing action?

inspect the area

the nurse notes that a client has longitudinal ridges in the nails of both thumbs. what should the nurse consider as being the reason for this finding?

normal finding

when using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

notched border, diameter greater than 6 cm, asymmetry

while assessing an adult client, the nurse observed an elevated, palpable, solid mass with a circumcised border that measures 0.75 cm. the nurse documents this as a ...

papule.

the nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

pressure ulcer

a nurse assess a client for past history of nail problems. the nurse should ask questions about which of these conditions?

psoriasis, fungal infections, trauma

a group of students are reviewing the structure and function of the skin in preparation for a test on the material. the students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

stratum corneum

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.

an elderly client comes to the clinic for evaluation. during the skin assessment, the nurse notes considerable skin tenting. why does this finding require further assessment?

tenting indicates dehydration

a nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. which aspect of the client's current health status would be reflected in her on this scale?

the client is consistently in contingent of urine

why is it important for the nurse to ask the client what they think caused a skin condition?

the client's perception affects the approach and effectiveness in treating the skin condition

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

a patient asks, "what does SPF 15 mean when considering a sunscreen?" what information should the nurse use to base the response to this patient's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

a nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. how should the nurse best explain the rationale for this subjective assessment?

"having bad sunburns when you're a child puts you at risk for skin cancer later in life."

a 72-year-ole 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

what is the most important focus area for the integumentary system?

UV radiation exposure

assessment of a client's nails reveals the presence of Beau's lines. the nurse interprets this finding as suggestive of which of the following?

acute illness

a nurse notes that a client looks much older than his chronologic age. which of the following conditions would most likely contribute to this appearance?

alcoholism

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

allow early identification of neurologic deficits

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

areola of the breast.

why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

can be caused by an underlying systemic illness

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

dermis

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

A female client is noted to have excessive hair on her face and chest. The nurse plans further evaluation of which body system?

endocrine

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.

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

during an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. the nurse knows the client needs medical follow-up for further assessment to rule out which condition?

iron deficiency anemia

mrs. hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). she has noticed a raised dark red rash on her legs. when the nurse presses on the rash, it doesn't blanch. what would the nurse tell the client regarding her rash?

it is likely to be related to her lupus

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

keloid formation at the site of an old incision

a client is 20 weeks pregnant and has melasma. what information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

melasma generally resolves postpartum

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 limits. the nurse knows that the blue color the patient described is caused by what?

peripheral cyanosis

a new mother is concerned that her child occasionally "turns blue." on further questioning, she mentions that this occurs at the child's hands and feet. she does not remember the child's lips turning blue. the mother says that the child is eating and growing well. what should the nurse do?

reassure the mother that this is normal

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.

a client presents to the health care clinic with reports of changes in skin. which data should the nurse document as objective with regards to the skin?

skin warm and dry to the touch

what clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

spooning

a nurse has been asked to assess an older adult resident of a long-term care facility. during assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. inspection reveals that the areas appears blister-like. the nurse should interpret this finding as indicating which stage of pressure ulcer?

stage II

the nurse assess an older adult bedridden client in her home. while assessing the client's buttocks, the nurse observed 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.

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

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

the client's ability to change position

a nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. she asks her, "do you spend long periods of time sitting or lying in one position?" which of the following is the best rationale for asking this question?

to determine the clients risk for pressure ulcers

a decrease in oxyhemoglobin will result in documentation of pallor. t or f?

true

a patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. when the patient questions why this is true, the nurse will base the response on what psychological event that occurred as a result of the burn?

destruction of hair follicles located in the dermis layer

the nurse is preparing to examine a client's skin. what would the nurse do next?

expose only the body part that is being examined.

a client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. the client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. the nurse should ask the client questions related to the onset of which disease process?

hypothyroidism

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

keratinized epidermal cells.

which situations should the nurse identify as being risk factors of the development of pressure sores?

pressure that impairs capillary blood flow to the skin, friction created by dragging the skin against bed linen, shearing that occurs when sliding down in bed, moisture being allowed to accumulate on the skin

a nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. what assessment parameter will the nurse evaluate when using this scale?

the client's ability to change position

a nurse is admitting an elderly client for surgery the following morning. the nurse notices that the client had excessively dry skin. the client says showering every day, sometimes twice, but has trouble keeping skin moist. what client education is appropriate?

the elderly should bathe or shower only every 2 to 3 days

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

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

touch with the palmar surface of the three middle fingers

local redness of the skin warns of impending necrosis. t or f?

true

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

wood's light

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

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