Chapter 14- Assessing Hair, Skin, Nails

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 Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

A risk involved with tattooing includes burning sensations when undergoing magnetic resonance imagining (MRI). Tattoos does not affect x-rays, blood glucose levels, or response to dye injected for a CT scan.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

How should the nurse palpate the skin of a client to assess its texture?

The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible. This ulcer does not increase the client's risk for developing osteopenia, osteoporosis, or osteoarthritis. Osteomyelitis = inflammation or swelling that occurs in the bone

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?

Tinea corporis In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

Vesicles vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue Blue-green fluorescence indicates fungal infection.

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

distribution/location

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

inspect If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

psorarisis Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

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 A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

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

pustular acne Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

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 2 A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

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

macules Freckles are flat, small macules of pigment that appear following sun exposure.

Squamous cell carcinoma is associated with

overall amount of sun exposure

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

palmar

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

vitamin D synthesis

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

wood's light

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch" A nurse needs to validate any subjective information that either does not fit with the rest of the information supplied by the client or any information that may indicate a problem exists. Cold feet that are painful need to be validated by careful assessment of the client's circulation. Dry and itchy skin is expected in the winter when the air is dry. Previous history of cancer and a port wine spot are past of the past medical history.

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden Scale Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.

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?

Document the findings in the client's record as normal Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating.

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 or 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?

Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Cushing disease can result in female facial hair growth.

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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?

Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?

Skin tags are common benign skin lesions

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?

Psoriasis This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

Connecting the skin to underlying structures is/are the

Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures. (papillae connect the dermis to epidermis)

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies.

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?

Trichotillomania or compulsive hair pulling is associated with a psychiatric disorder. Alopecia is a term used to describe general hair loss, most often associated with male pattern baldness, or a loss of hair from medications such as chemotherapy. Hirsutism is the appearance of hair on the face of a female. Tinea capitis causes round areas of alopecia on the scalp of a person with a fungus infection.

What is the most important focus area for the integumentary system?

UV radiation

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

VESICLES Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis. Cyanosis may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

ashen Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

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. Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

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?

chronic hypoxia Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

Which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility (how much skin can move) The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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

fainting Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

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 Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia

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?

impetigo

A client with a zosteriform rash has a rash that

is distributed along a dermatome A zosteriform rash is distributed along a dermatome.

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

melanin The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

melanoma

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

pinch the forearm To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the client's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

pits in nails Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

recent illness

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?

smoking history

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

spooning Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.

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

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

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:

stress Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

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?

under breast The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarm The apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress. This type of gland does not secret on locations identified by the other options.

To assess an adult client's skin turgor, the nurse should

use two fingers to pinch the skin under the clavicle.

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?

uticaria/hives This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

Short, pale, and fine hair that is present over much of the body is termed

vellus