Chapter 14 - Assessing Skin, Hair, and Nails

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?

"Do you feel anxious at times?"

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse?

"It sounds like you have developed peripheral neuropathy."

Macule and Patch

- Small, flat, non-palpable skin color change - Brown, white, tan, purple, red - Macules less than 1 cm with circumscribed border - Patches greater than 1 cm, irregular border - EX. freckles, flat moles, petechiae, rubella, vitiligo, port wine stains, and ecchymosis

The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash?

Allergic reaction

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

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?

Cushing's disease

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

Distribution

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

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

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

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

Palmar surfaces

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?

Psoriasis

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

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

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

UV radiation exposure

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

Wood's light

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

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 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 client with a zosteriform rash has a rash that

is distributed along a dermatome

When documenting that a client has freckles, the appropriate term to use is

macules

_____ is an oily substance that lubricates hair and skin and reduces water loss

sebum

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

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries

Carotene is responsible for yellow color of the skin.

true

Spoon nails are a characteristic feature of iron deficiency anemia

true

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

use two fingers to pinch the skin under the clavicle

_____ or (peach fuzz) is short, pale, fine, and present over much of the body

vellus hair

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 nursing instructor is teaching nursing students about hair. Which of the following statements represents the students' understanding of hair? Select all that apply.

- "there are two types of hair: vellus & terminal" - "hair grows on most of the body except some areas such as lips" - "nasal hair filters dust and other airborne debris"

When inspecting the hair, what would the nurse note? (Select all that apply.)

- color - condition of hair shaft - hair shafts that are shiny

Cyst

- encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis - EX. include sebaceous cyst and epidermoid cyst

Erosion

- loss of superficial epidermis that does not extend to the dermis - depressed, moist area - EX. rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, "canker sore")

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

Keloid formation at the site of an old incision

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

Osteomyelitis

Which technique should the nurse use to properly assess a client's skin turgor?

Pinch the skin over the clavicle and observe its return to the original shape

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?

Skin warm and dry to the touch

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

fainting

Pressure areas in stage 1 involve epidermis, dermis, and subcutaneous tissues

false

A linear crack in the skin that may extend to the dermis and may be painful is called a ______

fissure

A nurse observes yellow, thick, crumbling toenails on a new client. The nurse suspects which of the following conditions?

fungal infection

Squamous cell carcinoma is associated with

overall amount of sun exposure

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

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?

"How has it changed?"

Vesicle and bulla

- Circumscribed, elevated, palpable mass containing serous fluid - vesicles are less than 0.5cm - bullas are greater than 0.5 cm - EX. vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn - EX. bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo

Ulcer

- skin loss extending past epidermis, with necrotic tissue loss - bleeding and scarring are possible - EX. stasis ulcer of venous insufficiency and pressure injury

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken with the presence of a blister

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

"It takes about 6 months to totally replace a fingernail."

Papule and Plaque

- elevated, palpable solid mass - papules have circumscribed border and less than 0.5 cm - plaques are greater than -.5 cm and coalesced papules with a flat top - EX. papules include elevated nevi, warts, and lichen planus - EX. of plaques include psoriasis and actinic keratosis

Fissure

- linear crack in the skin that may extend to the dermis and may be painful - EX. chapped lips or hands and athlete's foot, interdigital tinea pedis with fissures and maceration

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.

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

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast

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

dermis

A macule is an elevated, palpable, solid mass with circumscribed border

false

Perspiration increases with aging because sweat gland activity increases

false

______ refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched.

turgor

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

underarms

_____ lesions are configured in a linear manner and clustered along a nerve

zosteriform

Nodule and tumor

- Elevated, solid, palpable mass that extends deeper into dermis than a papule. - nodules are 0.5 - 2 cm and circumscribed - tumors are greater than 1-2cm and do not always have sharp borders - EX. nodules include keloid, lipoma, SCC, poorly absorbed injection, and dermatofibroma - EX. tumors include larger lipoma and carcinoma

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.

- disturbed body image - ineffective individual coping - anxiety

Wheal

- elevated mass with transient borders that are often irregular - size and color vary - caused by movement of serous fluid into the dermis - does not contain free fluid in a cavity (e.g., vesicle) - EX. include urticaria (hives), and insect bites

Pustule

- pus-filled vesicle or bulla - EX. acne, impetigo, furuncles, and carbuncles

Scar (cicatrix)

- skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue - young scars are red or purple - mature scares are white or glistening - EX. healed wound and healed surgical incision

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

Allow early identification of neurologic deficits

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

Carotene

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

ashen