PA Study Guide Ch. 14

14. 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

Ans: Stage II

11. A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

Abs: Sclera

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

Ans: A recent illness

12. 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

Ans: Are caused by aging of the skin in older adults

7. 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

Ans: Fluid intake

5. 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

Ans: Hypothyroidism

17. 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

Ans: Hypoxia

22. An African American female client visits the clinic. She tells the nurse that she has had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear. The nurse should document a

Ans: Keloid

19. While assessing an adult client, the nurse observes an elevated palpable, solid mass with a circumscribed border that measures 1cm. The nurse documents this as a

Ans: Plaque

23. 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 weeks. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

Ans: Risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions

3. 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

Ans: Squamous cell carcinomas are most common on body sites with heavy sun exposure

2. 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

Ans: Symptoms of stress

15. To assess an adult client's skin turgor, the nurse should

Ans: Use two fingers to pinch the skin under the clavicle

20. 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

Ans: Vesicles

9. To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

Ans: ashen

10. The nurse is assessing a dark-skinned client 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

Ans: A great degree of cyanosis

13. 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

Ans: Blue

4. The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to

Ans: Chronic discoid lupus erythematosus

1. An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing

Ans: Domestic abuse

21. 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 a linear cracks in the skin on booth feet. The nurse should document the presence of

Ans: Fissures

18. While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

Ans: Macules

6. 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

Ans: Malignant melanoma

8. 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

Ans: Oral mucosa