Assessment of Integumentary Function Ch. 60
Yellowish skin is noted in the patient diagnosed with:
jaundice
Local arterial insufficiency is characterized by marked:
localized pallor.
Alopecia
loss of hair from any cause
Conduction
Describes the transfer of heat from the body to a cooler object in contact with it; Conduction is one of the three major physical processes are involved in loss of heat from the body to the environment.
The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?
Psoriasis
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
Scale
Secondary lesion occurring in psoriasis.
Scale
Flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.
Scales
Elevated, thick-walled lesions containing fluid or semisolid matter.
Sebaceous cysts
Prevents drying and cracking of the skin and hair:
Sebum
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?
The skin is ashen gray and dull.
Lichenification
Thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?
Yellowish waxy deposits on the eyelids
Hypopigmentation
decrease in the melanin of the skin, resulting in a loss of pigmentation
Langerhans cells
dendritic clear cells in the epidermis that carry surface receptors for immunoglobulin and complement and that are active participants in delayed hypersensitivity of the skin
The purpose of melanin is to:
determine skin color.
Defined as loss of superficial epidermis that does not extend into the dermis.
erosions
Sebum
fatty secretion of the sebaceous glands
The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as:
fissure
Linear cracks in the skin are documented as:
fissures
Sebaceous glands
glands that exist within the epidermis and secrete sebum to keep the skin soft and pliable
In older adults, a decrease in melanin results in a change of (BLANK) color to gray.
hair
Hyperpigmentation
increase in the melanin of the skin, resulting in an increase in pigmentation
Concave or "spooning" fingernails may indicate:
iron-deficiency anemia
A skin biopsy
is done to rule out a malignancy and establish an exact diagnosis.
Tzanck smear
is used to examine cells from blistering skin conditions.
An increased angle between the nail plate and nail base.
Clubbing
Evated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid.
Vesicles
The transfer of heat from the body to a cooler object in contact with it.
Conduction
The transfer of heat through contact:
Conduction
Three major physical processes are involved in loss of heat from the body to the environment.
Conduction, radiation, convection
A condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky white spots.
Vitiligo
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?
Vitiligo
Used to differentiate epidermal from dermal lesions and hyperpigmented and hypopigmented lesions:
Wood's light examination
Dryness
Xerosis
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?
Conduction
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?
"Have you been eating a large amount of carotene-rich foods?"
Macule
A flat, round, colored lesion such as a freckle or rash.
Vesicle
A lesion that is elevated, round, and filled with serum.
A linear red or brown streak in the nail bed.
A splinter hemorrhage
Patients diagnosed with (BLANK BLANK) have a bronzed appearance, an "external tan."
Addison's disease
A condition of total absence of pigment in which the skin appears whitish pink.
Albinism
Pustule
An elevated, raised border, filled with pus.
Cyst
An encapsulated, round, fluid-filled or solid mass beneath the skin.
A horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth.
Beau's line
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?
Beau's line
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?
Bronze
Elevated, fluid-filled lesions greater than 0.5 cm in diameter; example is a 0.5 blister.
Bullae
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
Clubbing
A thick layer of epidermal cells that forms in response to recurring friction on an area of skin:
Callus
Term used to describe a bright red mole.
Cherry angioma
Consists of movement of warm air molecules away from the body—is the transfer of heat by conduction to the air surrounding the body.
Convection
Refers to color variations (vision)
Dyschromia
Contains an outer layer of dead skin that forms a tough protective protein called keratin.
Epidermis
Hundreds of strands of keratin link together with amino acids to form:
Hair
What body structures have keratin as part of their composition?
Hair, skin, and nails
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?
Jaundice
A yellowing of the skin, is directly related to elevations in serum bilirubin (>2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes.
Jaundice
Which factor causes wrinkles among older adults?
Loss of subcutaneous tissue
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?
Make sure that the room is darkened.
Refers to dark discoloration of the skin.
Melasma
Layers of hard keratin that have a protective function
Nails
Refers to itchy spots
Neurodermatitis
An inflammation of the skinfold at the nail margin.
Paronychia
A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely?
Patch testing
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
Pustule
The transfer of heat to another object of lower temperature situated at a distance.
Radiation
Refers to liver spots:
Solar lentigo
Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?
Spider angioma
Differentiating between a macule and a papule
The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, nonpalpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.
Beau's lines
Transverse depressions in the nail that may reflect retarded growth of the nail matrix because of severe illness or more commonly local trauma.
When assessing a patient's skin, the nurse would use palpation to assess which of the following?
Turgor
Skin loss that extends past the epidermis.
Ulcers
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?
Vesicles
Common examples of (BLANK) include blisters and the lesions caused by chickenpox and herpes simplex.
Vesicles
Xanthelasma
Yellowish waxy deposits on the eyelids; Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia.
Vitiligo
a localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches
Keratin
an insoluble, fibrous protein that forms the outer skin layer
Demonstrated as a dull skin appearance in brown- and black-skinned individuals:
anemia
In light-skinned individuals, generalized pallor is a manifestation of:
anemia
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of:
anemia
Keratinocytes
arising from the innermost layer of the epidermis, synthesize the insoluble protein, keratin
Shock due to decreased perfusion and vasoconstriction is indicated in (BLANK) skin as an ashen gray, dull appearance.
black
A condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.
carotenemia
Merkel cells
cells of the epidermis that play a role in transmission of sensory messages
Melanocytes
cells of the skin that produce melanin
Discolored or brittle nails may result from:
other disorders or smoking
Involves applying the suspected allergens, such as nickel or fragrances, to normal skin under occlusive patches. Patients wear these occluded strips on their backs for 48 hours, and the area is assessed after 72 hours.
patch testing
Performed to identify substances to which the patient has developed an allergy:
patch testing
Petechiae
pinpoint red spots that appear on the skin as a result of blood leakage into the skin
Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with (BLANK).
psoriasis
Erythema
redness of the skin caused by dilation of the capillaries due to injury, irritation, inflammation, or various skin conditions
Flakes secondary to desquamated, dead epithelium.
scales
Patients with renal failure may have a gray or orange-green cast to the (BLANK).
skin
Hirsutism
the condition of having excessive hair growth
Melanin
the substance responsible for coloration of the skin
Wood light
ultraviolet light used for diagnosing skin conditions
Rete ridges
undulations and furrows that appear at the lower edge of the epidermis at the dermal junction where these two skin layers are cemented together
Telangiectasias
venous stars; red marks on the skin caused by distention of the superficial blood vessels
A common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia.
xanthelasma