Skin, Hair and Nails Assessment

The nurse is assessing the client's hair, skin, and nails during the health assessment. The nurse uses which action to assess capillary refill?

Applies pressure to the nail beds. Capillary refill is assessed by pressing on the client's nail beds. Color should return briskly within 1 to 2 seconds. Palpating the skin surfaces, feeling the top of the skull, and touching the forehead with the back of the hand are other components of the hair, skin, and nail assessment.

The nurse is performing a focused assessment of the skin, hair, and nails. Which assessment findings would require immediate intervention? Select all that apply.

Blue tinge to all of the nail beds, Tenderness and edema to the left calf Tenderness and edema to one calf may indicate a deep vein thrombosis (DVT), and blue color to the nail beds may be cyanosis and indicate hypoxia. Both of these findings require immediate action and further assessments. Generalized pallor may be normal or indicate anemia, inflamed red itchy patches are usually eczema, and complete absence of pigmentation is albinism. None of these conditions require immediate attention.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

Circumoral cyanosis when the client is at rest Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, African-American, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

The nurse is admitting a client with diabetes and a stage II wound to the right heel. When assessing the client's skin, what would the nurse do first?

Inspect overall skin color. Inspection should always be done first. Assess whether overall color is consistent with ethnicity. The nurse could then palpate for skin temperature, compare the texture of the arms, and measure the length, width, and depth of any existing wound present.

The nurse is reviewing the lab work of a client who has a serum bilirubin level of 0.5 mg/dL (8.55 µmol/L). What assessment findings would the nurse expect when conducting a focused skin assessment of this client? Select all that apply.

Jaundice of the sclera, Generalized pruritus Jaundice to the skin, sclera, and palate, as well as pruritus would be observed in the client with an elevated serum bilirubin. The other findings are not observed with an elevated serum bilirubin or liver issues.

A nurse is preparing to perform a focused hair and scalp assessment on an 8-year-old client who reports, "my head has been itchy for the past couple days." What should the nurse do first?

Put on a pair of gloves. Because the client is reporting itching to the scalp for the past couple days, there is a possibility of infestation. The nurse needs to put on gloves before starting the rest of the assessment. The nurse would use a flashlight to examine hair for any lice or nits. The nurse may ask the client to describe or rate the itching, but the priority would be to put on gloves and then assess the hair and scalp.

Which are included in the integumentary system? Select all that apply.

Skin, Nails, Hair, Sweat glands The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands. Arteries are included in the cardiovascular or peripheral vascular systems, and muscles are included in the musculoskeletal system.

During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique?

To assess capillary refill and oxygenation Palpation of the nails is done to assess capillary refill and oxygenation. The other answers pertain to assessment of the skin.