assessing skin, hair, and nails

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? a) Around the mouth and lips b) Nose and earlobes c) Fingers and toes d) Chest and abdomen

c) Fingers and toes

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

d) Psoriasis, fungal infections, trauma

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? a) Skin warm and dry to the touch b) Denies any skin color changes c) Dry and flaky skin in the winter months d) Small lesion left forearm for one month

a) Skin warm and dry to the touch

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

b) History of cigarette smoking

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos of other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? a) Diabetes mellitus b) Hypothyroidism c) Chrons disease d) Liver disease

b) Hypothyroidism

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? a) Nodule b) Macule c) Vesicle d) Papule

b) Macule

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? a) perioral b) palms c) facial d) chest

a) perioral

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? a) Lupus erythematosus b) Cushing's disease c) Iron deficiency anemia d) Basal cell carcinoma

b) Cushing's disease

Which clinical manifestation should the nurse expect to find in a client with edema? a) Mottled skin tones b) Decreased skin turgor c) Decreased skin mobility d) Prominent blood vessels

c) Decreased skin mobility

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? a) Monitor the client for additional findings of cystic fibrosis b)Suggest that the client use antiperspirant products c) Document the findings in the client's record as normal d) Assess the client for changes in sensation due to vascular problems

c) Document the findings in the client's record as normal

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse? a) Ask the client about any injury to the nails b) Report the finding to the health care provider c) Document this a normal finding d) Assess for adequate capillary refill time

c) Document this a normal finding

A nurse implements which skin assessment to determine the presence of dehydration in a client? a) Temperature b) Texture c) Turgor d) Thickness

c) Turgor

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that it has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and must wear socks to bed. Which nursing diagnosis can be confirmed from this data? a) Risk for Impaired Skin Integrity b) Risk for Imbalanced Body Temperature c) Disturbed Body Image d) Altered Tissue Perfusion

a) Risk for Impaired Skin Integrity

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

a) Wood's light

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

b) Spooning

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? a) Anterior chest b) Under the breast c) Upper abdomen d) On the neck

b) Under the breast

Upon examination of a client, the nurse finds a circumcised elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? a) Wheal b) Vesicle c) Cyst d) Papule

b) Vesicle

Which statement by a client about the skin needs validation by the collection of objective data by the nurse? a) "My port wine birth mark has not gotten any bigger" b) "I had a small skin cancer removed about 3 years ago" c) "My feet hurt and are always cold to the touch" d) "I experience itchy and dry skin every winter"

c) "My feet hurt and are always cold to the touch"

A nurse cares for a patient with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? a) Ulceration resembling a crater b) Exposure of subcutaneous tissue and muscle c) Broken with the presence of a blister d) Unbroken but red in color

c) Broken with the presence of a blister

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? a) Nail problems may affect a persons body image negatively b) Local irritation can cause damage to the nail bed c) Nail problems can be caused by an underlying systemic illness d) Abnormalities may be a sign of poor hygiene

c) Nail problems can be caused by an underlying systemic illness

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

c) Touch with the palmar surface of the three middle fingers

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? a) Psoriasis b) Herpes zoster c) Viral Exanthum d) Impetigo

d) Impetigo

Which technique should the nurse use to properly assess a client's skin turgor? a) Palpate the skin on the sternum to determine its flexibility b) Palpate the skin around the umbilicus to assess for intactness c) Pinch the skin on the abdomen and observe for color changes d) Pinch the skin over the clavicle and observe its return to the original shape

d) Pinch the skin over the clavicle and observe its return to the original shape

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

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

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? a) Color is uniform b) Diameter is less than 1/8 of an inch c) Asymmetrical shape d) Borders well demarcated

c) Asymmetrical shape