Jensen Ch. 11

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? a) "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." b) "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." c) "Repeated sunburns in childhood may explain the presence of some of your moles." d) "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

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? a) "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn." b) "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." c) "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." d) "SPF 15 is the number of minutes that a person can safely stay in the sun after treating the skin with the product."

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

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as a) 9 b) 15 c) 13 d) 11

15

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? a) 9 or lower b) 13 to 18 c) 19 to 23 d) 10 to 12

19 - 23 Levels of risk for developing pressure ulcers are rated according to the following scores: • 19 to 23: not at risk • 15 to 18: mild risk • 13 to 14: moderate risk • 10 to 12: high risk • 9 or lower: very high risk

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? a) 3 b) 4 c) 2 d) 1

3 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 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? a) 4 b) 3 c) 1 d) 2

3 *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

Which of the following terms is used to describe the arrangement of skin lesions? a) Annular b) Localized c) Generalized d) Exposed

Annular Annular, or arciform, lesions are typical of the pattern and arrangement associated with tinea faciale. The terms exposed, localized, and generalized are not commonly used to describe the arrangement of lesions.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma? a) Diameter less than 1/8 of an inch b) Color is uniform c) Asymmetrical shape d) Borders well demarcated

Asymmetrical shape Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? a) Circulatory disorder b) Yeast infection c) Bacterial infection d) Fungal infection

Bacterial infection Bacterial infections cause green, black, or brown nail discoloration. Yellow, thick, crumbling nails are seen in fungal infections. Yeast infections cause a white color and nail separation of the plate from the bed. Impaired circulation does not cause this presentation.

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? a) Exposure of subcutaneous tissue and muscle b) Unbroken but red in color c) Ulceration resembling a crater d) Broken with the presence of a blister

Broken with the presence of a blister 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.

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? a) Integumentary b) Digestive c) Neurologic d) Circulatory

Circulatory A thickening of the nail is usually secondary to repeated trauma, fungal infection, or decreased vascular circulation. In an older adult, nails may appear thickened, yellow, and brittle because of decreased circulation.

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? a) Annular b) Clustered c) Linear d) Discrete

Clustered

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? a) Cushing's disease b) Iron deficiency anemia c) Lupus erythematosus d) Basal cell carcinoma

Cushing's disease *Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

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

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? a) Stratum lucidum b) Dermis c) Epidermis d) Stratum corneum

Dermis *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.

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for finding of which disease process? a) Diabetes mellitus b) Psoriasis c) Hypothyroidism d) Contact dermatitis

Diabetes mellitus The appearance of a rough and dark skin around the neck area, especially in African Americans, can be an indication of diabetes mellitus. This condition is called acanthosis nigricans. Psoriasis is a skin condition caused by overgrowth of desquamated, dead epithelium skin cells and causes a silvery white appearance to the skin. Hypothyroidism causes a generalized dryness to the skin. Contact dermatitis is a thickening and roughness of the skin caused by exposure to a substance that is an allergen, chemical, foods, or emotional stress.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? a) Colour b) Arrangement c) Distribution d) Type

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

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism? a) Dry and smooth b) Dry and rough c) Moist and rough d) Moist and smooth

Dry and Rough

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? a) Neurologic b) Endocrine c) Genitourinary d) Cardiovascular

Endocrine

When preparing to examine a client's skin, which of the following would be most important for the nurse to do? a) Ensure that the room is warm to prevent chilling b) Wear gloves when preparing to inspect the skin and nails c) Expose only the body part that is being examined d) Have the client remove clothing from the upper body

Expose only the body part that is being examined

The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do? a) Expose only the body part that is being examined. b) Ensure that the room is hot to prevent chilling. c) Have the client remove clothing from the upper body. d) Wear gloves when preparing to inspect the skin and nails.

Expose only the body part that is being examined.

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition? a) Fingers and toes b) Nose and earlobes c) Chest and abdomen d) Around the mouth and lips

Fingers and toes Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.

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? a) Crohn's disease b) Liver disease c) Diabetes mellitus d) Hypothyroidism

Hypothyroidism

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 a) hypothyroidism. b) hyperthyroidism. c) infectious conditions. d) hypoparathyroidism.

Hypothyroidism *Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? a) Test whether gentle abrasion with an emery board is painful. b) Apply hydrogen peroxide to see whether the client's pruritus is relieved. c) Illuminate the area using a Wood's light. d) Perform a trial with a topical antibiotic.

Illuminate the area using a Wood's light.

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a a) lichenification. b) bulla. c) cyst. d) keloid.

Keloid Nodules and tumors are elevated, solid, palpable masses that extends deeper into dermis than a papule. Nodules are 0.5-2 cm and circumscribed; tumors are greater than 1-2 cm and do not always have sharp borders. Examples of nodules include a keloid.

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? a) Nodule b) Vesicle c) Macule d) Papule

Macule *A macule is a flat, non-palpable 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 it size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

When documenting that a patient has freckles, the appropriate term to use is a) macules b) bullae c) vesicles d) patches

Macules Macules are skin discolorations that are flat, circumscribed, discolored, and less than 1 cm in diameter. An example of a macule is a freckle.

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? a) Melasma is always permanent b) Melasma can be treated with Betadine ointment c) Melasma generally resolves postpartum d) Melasma should be treated with antibiotics

Melasma generally resolves postpartum *Melasma, increased pigmentation of the face in response to the hormonal changes of pregnancy, occurs mainly on the chin, cheeks, and upper lip and generally resolves postpartum but can be permanent. Melasma is not a condition that is treated with Betadine or antibiotics.

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? a) Yearly b) Quarterly c) Bimonthly d) Monthly

Monthly

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a a) macule. b) papule. c) patch. d) plaque.

Papule Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

A 15-year-old boy shows the school nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? a) Macule b) Nodule c) Pustule d) Papule

Papule *A papule is a solid, elevated, circumscribed skin lesion that does not contain serous or purulent fluid. A macule is a flat nonpalpable skin color change usually less than 1 cm in size. A nodule is an elevated solid palpable mass between 0.5 to 2 cm in size. A pustule is pus-filled vesicle or bulla (circumscribed elevated mass).

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? a) Ask the client about a family history of cancer. b) Document the benign findings. c) Refer the client for medical follow-up. d) Perform a random blood sugar test.

Perform a random blood sugar test. Linear hyperpigmented areas (acanthosis nigricans) present in the skin of the neck, axillae, and perianal folds in dark-skinned people suggest diabetes mellitus. A random blood sugar test would provide an objective assessment to identify hyperglycemia. The findings are not indicative of skin cancer, nor are they benign. The client may be referred for medical follow-up after additional assessment is completed.

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? a) Peripheral cyanosis b) Neurofibromatosis c) Central cyanosis d) Reynaud disease

Peripheral cyanosis

In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? a) Multiple sclerosis b) Psoriasis c) Malignant melanoma d) Peripheral vascular disease

Peripheral vascular disease Peripheral vascular disease decreases the circulation of the periphery of the body, causing hypoxia and a capillary refill of greater than 2 seconds. Psoriasis, multiple sclerosis, and malignant melanoma are not associated with changes in capillary refill.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? a) Purpura b) Cherry angioma c) Ecchymosis d) Petechiae

Petechiae

Which technique should the nurse use to properly assess a client's skin turgor? a) Palpate the skin on the sternum to determine its flexibility b) Pinch the skin on the sternum and observe its return to the original shape. c) Pinch the skin on the abdomen and observe for color changes d) Palpate the skin around the umbilicus to assess for intactness

Pinch the skin on the sternum and observe its return to the original shape.

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? a) Seborrheic keratosis b) Pressure ulcer c) Cutaneous horn d) Cherry angioma

Pressure ulcer

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? a) Psoriasis, fungal infections, trauma b) Vitiligo, hirsutism, vitamin deficiency c) Eczema, melanoma, herpes zoster d) Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma 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.

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? a) Stage III b) Stage II c) Stage I d) Stage IV

Stage 2

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? a) Stage III b) Stage II c) Stage I d) Stage IV

Stage II *A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

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? a) Stratum corneum b) Stratum granulosum c) Stratum lucidum d) Stratum germinativum

Stratum corneum The epidermis consists of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum, in that order.

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? a) Tenting indicates dehydration b) Tenting indicates dramatic weight loss c) Tenting indicates vitamin B12 deficiency d) Tenting indicates malnutrition

Tenting indicates dehydration

Which of the following findings related to hair would the nurse most likely assess in an older adult female client? a) Increased pubic hair b) Terminal hair growth on chin c) Copper-red color d) Thick elastic scalp hair

Terminal hair growth on chin

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? a) The client has melanoma b) The client has chronic hypoxia c) The client has asthma d) The client has COPD

The client has chronic hypoxia

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? a) The client has melanoma b) The client has chronic hypoxia c) The client has asthma d) The client has COPD

The client has chronic hypoxia 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.

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 score on this scale? a) The client has a surgical diagnosis. b) The client has a full-time caregiver. c) The client adheres to a vegetarian diet. d) The client is consistently incontinent of urine.

The client is consistently incontinent of urine. *The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

Why is it important for the nurse to ask the client what they think caused a skin condition? a) The client's perception affects the approach and effectiveness in treating the skin condition b) The nurse can alleviate the client's fears about what caused the skin condition c) Doing so allows the client to decide what treatment is the best course of action d) Doing so encourages the client to use home remedies to reduce medical cost

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

The nurse is admitting a 79-year-old man for outpatient surgery. The patient 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? a) The patient may have a cognitive deficit. b) The patient may have been abused. c) The patient is elderly. d) The patient may have peripheral vascular disease.

The patient may have been abused.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer? a) There is a nonblanching reddened area on the client's coccyx region. b) There is a generalized rash on the client's lower back and buttocks. c) There is noticeable bruising on and around the client's coccyx region. d) There is scant, frank blood present on the skin surfaces surrounding the client's coccyx.

There is a nonblanching reddened area on the client's coccyx region. Nonblanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

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? a) Tinea corporis b) Multiple nevi c) Herpes simplex d) Tinea versicolor

Tinea corporis 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.

A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis? a) Atopic eczema b) Pityriasis rosea c) Psoriasis d) Tinea versicolor

Tinea versicolor

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? a) Anterior chest b) Upper abdomen c) Under the breast d) On the neck

Under the breast *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.

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? a) Purpura b) Psoriasis c) Insect bites d) Urticaria or hives

Urticaria or hives

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? a) Have a nurse who is the same sex as the client examine him b) Allow the client to pray before the examination c) Let the client remained fully dressed for the examination d) Avoid asking any questions regarding the client's lifestyle

a) Have a nurse who is the same sex as the client examine him *Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client.

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

areola of the breast.

Which statement by a client about the skin needs validation by the collection of objective data by the nurse? a) "I experience itchy and dry skin every winter" b) "My feet hurt and are always cold to the touch" c) "My port wine birth mark has not gotten any bigger" d) "I had a small skin cancer removed about 3 years ago"

b) "My feet hurt and are always cold to the touch" 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.

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 a) red. b) blue. c) purple. d) yellow.

blue.

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 a) signs of dermatitis. b) signs of an infectious process. c) caused by aging of the skin in older adults. d) precancerous lesions.

caused by aging of the skin in older adults.

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 a) erosion. b) fissures. c) ulcers. d) scales.

fissures. Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

When documenting that a patient has freckles, the appropriate term to use is a) macules b) vesicles c) bullae d) patches

macules

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of a) macules. b) plaques. c) papules. d) bulla.

macules.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a a) papule. b) patch. c) macule. d) plaque.

papule.

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 a) scabies b) ticks c) allergies d) lice

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

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 a) allergies b) lice c) ticks d) scabies

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

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

squamous cell carcinomas are most common on body sites with heavy sun exposure. quamous cell carcinoma is most common on body sites with very heavy sun exposure.

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 a) allergies to certain foods. b) pigmentation irregularities. c) symptoms of stress. d) recent radiation therapy.

symptoms of stress.

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 a) vesicles. b) bullae. c) wheals. d) nodules.

vesicles.

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 a) nodules. b) wheals. c) bullae. d) vesicles.

vesicles. 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.

Upon assessment, the nurse notes the client's skin to be dry and thin. The nurse understands that is is related to what? Select all that apply. a) Decreased apocrine production b) Decreased turgor c) Increased apocrine production d) Decreased eccrine production e) Increased eccrine production

• Decreased apocrine production • Decreased eccrine production Part of the aging process includes decreased eccrine and apocrine production which leads to skin dryness Turgor is a measure of elasticity.

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply. a) Impaired Skin Integrity b) Risk for Infection c) Disturbed Body Image d) Anxiety e) Ineffective Individual Coping

• Disturbed Body Image • Ineffective Individual Coping • Anxiety This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection.

What does examination of the skin involve? Select all that apply. a) Inspection b) Nutritional assessment c) Percussion d) Auscultation e) Palpation

• Inspection • Palpation

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. a) Moisture b) Age c) Nutrition d) Admitting diagnosis e) Activity

• Moisture • Nutrition • Activity Six factors are rated using a matrix scoring system: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

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. a) Protects against damage to the body from sunlight b) Circulates blood throughout the body c) Aids in maintaining body temperature d) Helps make vitamin D in the body e) Involved in digestion of food f) Largest organ of the body

• Protects against damage to the body from sunlight • Aids in maintaining body temperature • Helps make vitamin D in the body • Largest organ of the body