Skin, Hair, Nails PrepU

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document? Superficial Dermal Superficial-dermal Full thickness

Superficial

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: melanoma skin cancers are the most common type of cancers. African Americans are the least susceptible to skin cancers. squamous cell carcinomas are most common on body sites with heavy sun exposure. usually there are precursor lesions for basal cell carcinomas.

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

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? Perioral Facial Chest Palms

Perioral

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? Contact dermatitis Eczema Psoriasis Seborrhea

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Eczema, melanoma, herpes zoster Psoriasis, fungal infections, trauma Alopecia, dermatitis, chemotherapy Vitiligo, hirsutism, vitamin deficiency

Psoriasis, fungal infections, trauma

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? Transverse white lines in the nails White spots, or leukonychia, on the nail surfaces Small pits in the surfaces of the nails Beau's lines

Small pits in the surfaces of the nails

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? Paronychia Beau's lines Clubbing Spooning

Spooning

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had: radiation. chemotherapy. a recent illness. steroid therapy.

a recent illness.

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

fainting

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: purple. blue. yellow. red.

blue.

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: signs of an infectious process. caused by aging of the skin in older adults. signs of dermatitis. precancerous lesions.

caused by aging of the skin in older adults.

A client with a zosteriform rash has a rash that appears with a single lesion in close proximity to a larger lesion, as: if "orbiting" the larger lesion is distributed equally on both sides of the body is distributed along a dermatome has lesions distributed over a large body area

is distributed along a dermatome

A client's skin color depends on melanin and carotene contained in the skin, and the: vascularity of the apocrine glands. client's genetic background. volume of blood circulating in the dermis. number of lymph vessels near the dermis.

volume of blood circulating in the dermis.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1 ulceration involving the dermis 2 intact, firm skin with redness 3 full-thickness skin loss 4 necrosis with damage to underlying muscle

2 intact, firm skin with redness 1 ulceration involving the dermis 3. full-thickness skin loss 4 necrosis with damage to underlying muscle

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 45-year-old female with 10 year history of cigarette smoking 28-year-old Caucasian male who works in a paper mill 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years

55-year-old male who lived in California for 20 years

The student nurse learns that examining the skin can do all of the following except? Identify physical abuse Allow early identification of potentially cancerous lesions Allow early identification of neurologic deficits Reveal overhydration

Allow early identification of neurologic deficits

The nurse preparing to conduct an integumentary assessment will include which interventions when preparing the client for this examination? (Select all that apply.) Assisting the client to put on a gown. Wearing gloves when palpating lesions. Using cotton balls to assess for sensation. Providing adequate drapes. Using the mnemonic OLDCART as a guide.

Assisting the client to put on a gown. Wearing gloves when palpating lesions. Providing adequate drapes.

Recommended protective measures to avoid skin cancer include which of the following? Seeking biannual examination by a clinician after age 40 years Performing monthly skin self-examinations Avoiding sun exposure Knowing signs of skin cancer

Avoiding sun exposure

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? Exposure of subcutaneous tissue and muscle Unbroken but red in color Ulceration resembling a crater Broken with the presence of a blister

Broken with the presence of a blister

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? Place the client in Trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client. Push the client toward the head of the bed to prevent back injury. Lower the head of bed and pull the client up with both arms.

Call for help and use the draw sheet to move the client.

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Linear Discrete Clustered Annular

Clustered

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? Stratum lucidum Stratum corneum Dermis Epidermis

Dermis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Epidermis Subcutaneous layer Dermis Connective layer

Dermis

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Psoriasis Facial acne Facial lesions associated with herpes simplex

Keloid formation at the site of an old incision

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition? Around the mouth and lips Fingers and toes Nose and earlobes Chest and abdomen

Fingers and toes

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? Have a nurse who is the same sex as the client examine him Allow the client to pray before the examination Let the client remained fully dressed for the examination Avoid asking any questions regarding the client's lifestyle

Have a nurse who is the same sex as the client examine him

When assessing your new client, you note that he has no hair on his legs. What might this indicate about the client? He has a hormonal imbalance He has hyperthyroidism He has hypothyroidism He has peripheral artery disease

He has peripheral artery disease

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. Helps make vitamin D in the body Circulates blood throughout the body Involved in digestion of food Largest organ of the body Protects against damage to the body from sunlight Aids in maintaining body temperature

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

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client? Treatment for fungal infections in the past Onset of iron deficiency anemia Environmental exposure to chemicals History of cigarette smoking

History of cigarette smoking

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Inspect the area Ask further questions Document the statement Move on to next body system

Inspect the area

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. Moisture Nutrition Activity Age Admitting diagnosis

Moisture Nutrition Activity

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed? Osteoarthritis Osteopenia Osteomyelitis Osteoporosis

Osteomyelitis

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client? Pustular acne Bullous impetigo Chickenpox Cystic acne

Pustular acne

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply. Sweat glands Blood vessels Vernix Lymphatic vessels Fat cells

Sweat glands Blood vessels Lymphatic vessels

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? The client has COPD The client has asthma The client has melanoma The client has chronic hypoxia

The client has chronic hypoxia

Why is it important for the nurse to ask the client what they think caused a skin condition? The nurse can alleviate the client's fears about what caused the skin condition Doing so allows the client to decide what treatment is the best course of action Doing so encourages the client to use home remedies to reduce medical cost The client's perception affects the approach and effectiveness in treating the skin condition

The client's perception affects the approach and effectiveness in treating the skin condition

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? Herpes simplex Tinea corporis Multiple nevi Tinea versicolor

Tinea corporis

How should the nurse palpate the skin of a client to assess its texture? Touch with the palmar surface of the three middle fingers. Pinch and roll the skin between the fingers Rub the dorsal surface of the hand over the skin Press the fingertips to the skin surface

Touch with the palmar surface of the three middle fingers.

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion? Papule Wheal Pustule Erosion

Wheal

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Wood's light Flashlight Artificial light

Wood's light

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the: entire skin surface. soles of the feet. areola of the breast. adipose tissue.

areola of the breast.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears: greenish. ashen. bluish. olive.

ashen.

Hair follicles, sebaceous glands, and sweat glands originate from the: dermis. epidermis. keratinized tissue. eccrine glands.

dermis.

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? high moderate mild negligible

high

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: hyperthyroidism. hypothyroidism. infectious conditions. hypoparathyroidism.

hypothyroidism.

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: anemia. hypoxia. infection. trauma.

hypoxia.

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: basal cell carcinoma. malignant melanoma. actinic keratoses. squamous cell carcinoma.

malignant melanoma.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border diameter great than 6 mm asymmetry pink color

notched border diameter great than 6 mm asymmetry

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: sclera. oral mucosa. palms. nail beds.

oral mucosa.

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 week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is: risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. ineffective individual coping related to changes in appearance. anxiety related to loss of outdoor activities and altered skin appearance. dry flaking skin and dull dry hair as a result of disease.

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

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. stage III. stage I. stage IV.

stage II.

Connecting the skin to underlying structures is/are the: subcutaneous tissue. dermis layer. papillae. sebaceous glands.

subcutaneous tissue.

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: recent radiation therapy. symptoms of stress. allergies to certain foods. pigmentation irregularities.

symptoms of stress.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body? underarms face soles of the feet palms of the hands

underarms

Short, pale, and fine hair that is present over much of the body is termed: lanugo. vellus. dermal. terminal.

vellus.