PrepU health assessment ch 11

high

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?

stratum corneum layers of epidermis -stratum corneum -stratum lucidum -stratum granulosum -stratum germinativum

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?

Psoriasis, fungal infections, trauma

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Broken with the presence of a blister

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?

monthly

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?

alcoholism

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?

cushing's disease

A nurse observes the presence of hirsutism (growth of coarse hair on women like men hair) on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

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

characteristics of the skin

client may have been abused

The nurse is admitting a 79-year-old man for outpatient surgery. The client 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?

"Do you take steroid medications on a regular basis?"

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

excessive collagen formation

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?

Are you allergic to foods, medications, or other substances?

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

pressure ulcer

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

distribution

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

acne

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

UV radiation exposure (skin cancer)

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

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

tinea corporis

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?

skin warm and dry to the touch

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

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

tenting indicates dehydration

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?

avoiding sun exposure

Recommended protective measures to avoid skin cancer include which of the following?

fissures

How should a nurse document the presence of linear cracks on the skin of the feet? (word)

Urticaria (hives)

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?

areola of the breast

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

fainting

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

wood's light

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

where the nail meets the skin

What part of the toe or finger should the nurse assess for paronychia?

macules

When documenting that a client has freckles, the appropriate term to use is:

Expose only the body part that is being examined

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

under the breast

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?

blue

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

Can be caused by an underlying systemic illness

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

macule

flat, brown color change areas on the forearms

use two fingers to pinch the skin under the clavicle.

to assess skin turgor