Ch 14 Skin, Hair, Nails

13. The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an itching rash. Which question would be most important for the nurse to ask? A) Are you allergic to foods, medications, or other substances? B) Does anyone else in your family have a rash like this? C) How painful is your rash? D) What have you been doing to control the itching?

A) Are you allergic to foods, medications, or other substances?

19. Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A) Discrete B) Linear C) Annular D) Confluent

A) Discrete

5. The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? A) Endocrine B) Neurologic C) Cardiovascular D) Genitourinary

A) Endocrine

18. A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? A) Monthly B) Bimonthly C) Quarterly D) Yearly

A) Monthly

25. A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer? A) There is a nonblanching reddened area on the client's coccyx region. B) There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. C) There is noticeable bruising on and around the client's coccyx region. D) There is a generalized rash on the client's lower back and buttocks.

A) There is a nonblanching reddened area on the client's coccyx region.

24. The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? A) Vasoconstriction B) Hyperglycemia C) Hypoxemia D) Cardiopulmonary insufficiency

A) Vasoconstriction

28. The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? A) Vitiligo B) Striae C) Angiomas D) Albinism

A) Vitiligo

20. Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? A) Oxygen deficiency B) Acute illness C) Psoriasis D) Trauma

B) Acute illness

11. A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma? A) Solid, dark brown color B) Asymmetric, irregular borders C) Diameter of 3 mm D) Flat with silvery scales

B) Asymmetric, irregular borders

16. Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? A) Fungal infection B) Bacterial infection C) Yeast infection D) Circulatory disorder

B) Bacterial infection

14. A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic? A) Increased thickness and hair loss B) Increased thinness C) Pallor D) Erythema

B) Increased thinness

6. During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? A) Diabetes mellitus B) Iron deficiency anemia C) Vitamin A deficiency D) Peripheral vascular disease

B) Iron deficiency anemia

9. A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? A) Macule B) Papule C) Nodule D) Pustule

B) Papule

3. A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? A) Document the benign findings. B) Perform a random blood sugar test. C) Ask the client about a family history of cancer. D) Refer the client for medical follow-up.

B) Perform a random blood sugar test.

10. While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? A) Purpura B) Petechiae C) Ecchymosis D) Cherry angioma

B) Petechiae

8. 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? A) Stage I B) Stage II C) Stage III D) Stage IV

B) Stage II

29. 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? A) The client has a full-time caregiver. B) The client is consistently incontinent of urine. C) The client has a surgical diagnosis. D) The client adheres to a vegetarian diet.

B) The client is consistently incontinent of urine.

21. A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A) The client's current medication regimen B) The client's ability to change position C) The pigmentation of the client's skin D) The client's history of integumentary disorders

B) The client's ability to change position

12. An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? A) Papule B) Vesicle C) Bulla D) Crust

B) Vesicle

17. The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do? A) Ensure that the room is hot to prevent chilling. B) Wear gloves when preparing to inspect the skin and nails. C) Expose only the body part that is being examined. D) Have the client remove clothing from the upper body.

C) Expose only the body part that is being examined.

23. A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. During which of the following components of the assessment should the nurse wear gloves? A) When palpating the texture of the client's skin B) When palpating the client's hair C) When palpating lesions on the client's skin D) When palpating the client's nail beds for texture and capillary refill

C) When palpating lesions on the client's skin

15. An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? A) Integumentary B) Digestive C) Neurologic D) Circulatory

D) Circulatory

27. The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse consequently ask? A) Has anyone in your family ever been diagnosed with skin cancer? B) Have you ever been assessed for diabetes? C) What dietary supplements do you usually take? D) Do you take steroid medications on a regular basis?

D) Do you take steroid medications on a regular basis?

22. A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? A) Repeated sunburns in childhood may explain the presence of some of your moles. B) This is one of the assessments we use to determine whether your parents took good care of your skin when you were young. C) When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older. D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

D) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

26. A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? A) Test whether gentle abrasion with an emery board is painful. B) Apply hydrogen peroxide to see whether the client's pruritus is relieved. C) Perform a trial with a topical antibiotic. D) Illuminate the area using a Wood's light.

D) Illuminate the area using a Wood's light.

2. The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? A) Nail beds B) Sclerae C) Palms D) Oral mucosa

D) Oral mucosa

7. In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? A) Psoriasis B) Multiple sclerosis C) Malignant melanoma D) Peripheral vascular disease

D) Peripheral vascular disease

1. The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on which of the following topics? A) Management of dry skin B) Susceptibility to bruising C) Risks of fungal infections D) Risks of sun exposure

D) Risks of sun exposure

4. 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? A) Squamous cells B) Sweat glands C) Subcutaneous tissue D) Sebum production

D) Sebum production

30. A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? A) The lesions will be raised and have irregular borders. B) The lesions will be acutely painful. C) The lesions will produce eschar. D) The lesions will not be palpable.

D) The lesions will not be palpable.