Skin, Hair and Nails

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

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the client for a routine examination and tells the nurse that she continues to swim in the sunlight three times a week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

Domestic abuse

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

Chronic Discoid Lupus Erythematosus

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

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

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

Vesicles

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plan to measure the client's symptomatic lesions and measure the size of the client's

Use two fingers to pinch the skin under the clavicle

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

Ashen

To assess anemia on a dark skinned client, the nurse should observe the client's skin for a colour that appears

Plaque

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

Macules

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

A recent illness

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

Sclera

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

Hypoxia

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

Caused by aging of the skin in older adults

While assessing the skin of an older adult client, the nurse observed that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

Blue

While assessing an adult client's feet for fungal disease using a Wood's light, the nurse documents the presence of a fungus when the fluorescence is

Fissure

An adult male client visits the clinic and tells the nurse he believes he has athlete,s foot. The nurse observed that the client has linear cracks in the skin on both feet. The nurse should document the presence of

Symptoms of stress

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

Keloid

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 earlobe. The nurse should document a

Overall amount of sun exposure

Squamous cell carcinoma is associated with

Stage II

The nurse assesses 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

A great degree of cyanosis

The nurse is assessing a dark skinned client who has been transported to the emergency room by ambulance. When the nurse observes the client's skin appears pale, with blue tinged lips and oral mucosa, the nurse should document the presence of