PrepU Ch. 14: Assessing Skin, Hair, and Nails
Macule Chapter 14: Assessing Skin, Hair, and Nails - Page 273
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?
symptoms of stress Chapter 14: Assessing Skin, Hair, and Nails - Page 250
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:
subcutaneous tissue. Chapter 14: Assessing Skin, Hair, and Nails - Page 247
Connecting the skin to underlying structures is/are the
Urticaria or hives Chapter 14: Assessing Skin, Hair, and Nails - Page 273
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?
Psoriasis Chapter 14: Assessing Skin, Hair, and Nails - Page 273
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle Chapter 14: Assessing Skin, Hair, and Nails - Page 271-272
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
keratinized epidermal cells. Chapter 14: Assessing Skin, Hair, and Nails - Page 249
The nails, located on the distal phalanges of the fingers and toes, are composed of
D Chapter 14: Assessing Skin, Hair, and Nails - Page 247
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
asymmetry diameter great than 6 mm notched border Chapter 14: Assessing Skin, Hair, and Nails - Page 276
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)
macules. Chapter 14: Assessing Skin, Hair, and Nails - Page 265
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
Moisture Activity Nutrition Chapter 14: Assessing Skin, Hair, and Nails - Page 266-267
You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.
Impetigo Chapter 14: Assessing Skin, Hair, and Nails - Page 273
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?
vesicles. Chapter 14: Assessing Skin, Hair, and Nails - Page 273
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
55-year-old male who lived in California for 20 years Chapter 14: Assessing Skin, Hair, and Nails - Page 254
The nurse recognizes that which client is at greatest risk for the development of skin cancer?
use two fingers to pinch the skin under the clavicle. Chapter 14: Assessing Skin, Hair, and Nails - Page 261
To assess an adult client's skin turgor, the nurse should
caused by aging of the skin in older adults. Chapter 14: Assessing Skin, Hair, and Nails - Page 260
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
UV radiation exposure Chapter 14: Assessing Skin, Hair, and Nails - Page 252
What is the most important focus area for the integumentary system?
hypothyroidism. Chapter 14: Assessing Skin, Hair, and Nails - Page 250
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
Tinea corporis Chapter 14: Assessing Skin, Hair, and Nails - Page 277
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?
Cushing's disease Chapter 14: Assessing Skin, Hair, and Nails - Page 263
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?
The client has chronic hypoxia Chapter 14: Assessing Skin, Hair, and Nails - Page 264
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 sebaceous cyst Chapter 14: Assessing Skin, Hair, and Nails - Page 274
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?
stage II. Chapter 14: Assessing Skin, Hair, and Nails - Page 271
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 II. Chapter 14: Assessing Skin, Hair, and Nails - Page 271
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
ashen. Chapter 14: Assessing Skin, Hair, and Nails - Page 258
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
Spooning Chapter 14: Assessing Skin, Hair, and Nails - Page 264
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
Palmar surfaces Chapter 14: Assessing Skin, Hair, and Nails - Page 249
When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:
underarms Chapter 14: Assessing Skin, Hair, and Nails - Page 248-249
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
Macules Chapter 14: Assessing Skin, Hair, and Nails - Page 273
When documenting that a client has freckles, the appropriate term to use is
friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed pressure that impairs capillary blood flow to the skin moisture being allowed to accumulate on the skin Chapter 14: Assessing Skin, Hair, and Nails - Page 266-267
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply
Document the findings in the client's record as normal Chapter 14: Assessing Skin, Hair, and Nails - Page 250
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
stage II. Chapter 14: Assessing Skin, Hair, and Nails - Page 271
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
Call for help and use the draw sheet to move the client. Chapter 14: Assessing Skin, Hair, and Nails - Page 255
The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?
a great degree of cyanosis. Chapter 14: Assessing Skin, Hair, and Nails - Page 258
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
squamous cell carcinomas are most common on body sites with heavy sun exposure. Chapter 14: Assessing Skin, Hair, and Nails - Page 254
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
Have a nurse who is the same sex as the client examine him Chapter 14: Assessing Skin, Hair, and Nails - Page 257
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?
Dermis Chapter 14: Assessing Skin, Hair, and Nails - Page 248
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
areola of the breast. Chapter 14: Assessing Skin, Hair, and Nails - Page 248-249
Areola/ breast bud tissue
color Chapter 14: Assessing Skin, Hair, and Nails - Page 276
The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C?
Under the breast Chapter 14: Assessing Skin, Hair, and Nails - Page 259-260
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?
Skin warm and dry to the touch Chapter 14: Assessing Skin, Hair, and Nails - Page 257
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?
Inspect the area Chapter 14: Assessing Skin, Hair, and Nails - Page 257
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Dermis Chapter 14: Assessing Skin, Hair, and Nails - Page 248
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?
Keloid formation at the site of an old incision Chapter 14: Assessing Skin, Hair, and Nails - Page 260
Which of the following assessment findings most likely constitutes a secondary skin lesion?
pulse oximetry Chapter 14: Assessing Skin, Hair, and Nails - Page 264
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
Seborrheic keratosis Chapter 14: Assessing Skin, Hair, and Nails - Page 266
A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?
Asymmetrical shape Chapter 14: Assessing Skin, Hair, and Nails - Page 276
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?
Disturbed Body Image Ineffective Individual Coping Anxiety Chapter 14: Assessing Skin, Hair, and Nails - Page 270
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.
Carotene Chapter 14: Assessing Skin, Hair, and Nails - Page 247-248
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
Protects against damage to the body from sunlight Helps make vitamin D in the body Largest organ of the body Aids in maintaining body temperature Chapter 14: Assessing Skin, Hair, and Nails - Page 247
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.