Bates -- Chapter 9

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

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The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene

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?

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?

Dermis

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

Dermis

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?

Excessive collagen formation

The nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral cyanosis

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

Which of the following is an important function of the skin?

Synthesis of vitamin D

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

caused by aging of the skin in older adults.

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?

patchy, thin hair

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

pulse oximetry

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II

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.

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?

67-year-old White female

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

Hirsutism

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

Perioral

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?

Reassure the mother that this is normal.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

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 chronic hypoxia

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

The client is consistently incontinent of urine.

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

Vitiligo

A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown?

a 30-year-old male who sustained a spinal cord injury who is now paraplegic

A client comes to the clinic reporting red "itchy" skin. The nurse should assess the client for which of the following causes of pruritus? Select all that apply.

aging allergies new medications liver dysfunction

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

folliculitis

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

hypothyroidism

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

macules