chapter 11 jensen

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? 1 2 3 4

3

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

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

A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus

Cushings disease

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Type Colour Distribution Arrangement

Distribution

The apocrine glands are stimulated by what? Emotional stress Temperature Physical stress Overhydration

Emotional stress

A female client is noted to have excessive hair on her face and chest. The nurse plans further evaluation of which body system? Endocrine Neurologic Cardiovascular Genitourinary

Endocrine

A patient, with a family history of melanoma, wants to have specific body moles assessed. In order to perform this assessment effectively, the nurse should have access to what equipment? (Select all that apply.) Warm water Examination table Chair Mask Natural lighting

Examination table Chair Natural lighting

When preparing to examine a client's skin, which of the following would be most important for the nurse to do? Ensure that the room is warm to prevent chilling Wear gloves when preparing to inspect the skin and nails Expose only the body part that is being examined Have the client remove clothing from the upper body

Expose only the body part that is being examined

A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify which of the following as an example? Cutaneous tags Striae Vitiligo Fissure

Fissure

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

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

Keloid formation at the site of an old incision

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following? Purpura Petechiae Ecchymosis Cherry angioma

Petechiae

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Cherry angioma Cutaneous horn Seborrheic keratosis Pressure ulcer

Pressure ulcer

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings? Eczema Pityriasis rosea Psoriasis Tinea infection

Psoriasis

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

Skin warm and dry to the touch

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 has a full-time caregiver. The client is consistently incontinent of urine. The client has a surgical diagnosis. The client adheres to a vegetarian diet.

The client is consistently incontinent of urine.

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect? Addison disease Vitiligo Tinea versicolor Dermatomyositis

Vitiligo

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 Striae Angiomas Albinism

Vitiligo

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply. the loss of skin turgor as a result of aging a cancerous skin lesion located on the back presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation

a cancerous skin lesion located on the back presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation

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

areola of the breast.

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

fainting

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. hyperthyroidism. infectious conditions. hypoparathyroidism.

hypothyroidism.

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 cm asymmetry pink color

notched border diameter great than 6 cm asymmetry

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. usually there are precursor lesions for basal cell carcinomas. squamous cell carcinomas are most common on body sites with heavy sun exposure.

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

A patient admitted with dehydration would typically have a decrease in skin turgor. True False

true

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

vellus

Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what? Acne Psoriasis Varicella Herpes simplex

Acne

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? Newton scale Head-to-toe assessment Norton scale Braden scale

Braden scale

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? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus

Cushing's disease

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? Onset of iron deficiency anemia History of cigarette smoking Environmental exposure to chemicals Treatment for fungal infections in the past

History of cigarette smoking

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? It is likely to be related to her lupus. It is likely to be related to an exposure to a chemical. It is likely to be related to an allergic reaction. It should not cause any problems.

It is likely to be related to her lupus.

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? Nodule Papule Vesicle Macule

Macule

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Nail beds Sclera Palms Oral mucosa

Oral mucosa

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

Pinch the skin on the sternum and observe its return to the original shape.

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

Pustular acne

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 I Stage II Stage III Stage IV

Stage II

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis? Stratum corneum Stratum lucidum Stratum granulosum Stratum germinativum

Stratum corneum

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? The client's current medication regimen The client's ability to change position The pigmentation of the client's skin The client's history of integumentary disorders

The client's ability to change position

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate? The elderly should bathe or shower only every 2 to 3 days The elderly should only bathe or shower once a week The elderly should bathe or shower daily but use lots of moisturizer The elderly should bathe or shower once every 2 weeks

The elderly should bathe or shower only every 2 to 3 days

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

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

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? Multiple nevi Tinea versicolor Herpes simplex Tinea corporis

Tinea corporis

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? Papule Vesicle Bulla Crust

Vesicle

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? When palpating the texture of the client's skin When palpating the client's hair When palpating lesions on the client's skin When palpating the client's nail beds for texture and capillary refill

When palpating lesions on the client's skin

When documenting that a patient has freckles, the appropriate term to use is macules patches vesicles bullae

macules

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

macules.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a plaque. macule. papule. patch.

papule

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 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.

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

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by scabies lice ticks allergies

scabies

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 I. stage II. stage III. stage IV.

stage II.

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

underarms

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? Repeated sunburns in childhood may explain the presence of some of your moles. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

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

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "These are considered a normal age-related change in the skin." "It means you have skin cancer and need to have them removed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."

"These are considered a normal age-related change in the skin."

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Alcoholism Parkinsons disease Marfans syndrome Cushings syndrome

Alcoholism

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? Are you allergic to foods, medications, or other substances? "Does anyone else in your family have a rash like this?" "Have you ever had a rash like this before?" "What have you been doing to control the itching?"

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

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

Psoriasis, fungal infections, trauma

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown? Eschar on an area near a bony prominence Excessive sweating on a dependent body region Skin that feels boggy on palpation Loss of the dermis

Skin that feels boggy on palpation

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

symptoms of stress.