Chapter 14: Assessing Skin, Hair, and Nails
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 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? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister
Broken with the presence of a blister Explanation: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.
What are some things that occurs w/ people w/ Liver disease
Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.
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 Explanation: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.
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? Insect bites Urticaria or hives Psoriasis Purpura
Urticaria or hives Explanation: 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.
What is Crohn's disease?
Crohns disease is an inflammatory process in the large intestines.
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin....
Vitamin D
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
Carotene
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 Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Deoxyhemoglobin Carotene Melanin
Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.
The nurse observes the client's lower extremities as shown (pic of dude w/ tattoo). What should the nurse focus on when teaching this client about upcoming diagnostic tests? Burning when having an MRI Inaccurate results when having a leg X-ray Falsely elevated serum blood glucose levels Allergic response to dye when having a CT scan
Burning when having an MRI Explanation: 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.
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 Explanation: A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.
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
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 Explanation: A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Artificial light Wood's light Flashlight
Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.
A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.) Synthesis of vitamin D Regulation of body temperature Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes
Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes Explanation: The skin provides a barrier protecting the body from injury caused by mechanical or chemical sources, penetration by microorganisms, and the loss of water and electrolytes. Regulation of body temperature is another function of the skin that allows heat to dissipate through sweat glands or permit heat storage through subcutaneous tissue. Synthesis of vitamin D is another function of the skin that occurs from cholesterol by the action of ultraviolet light. While the skin is a factor in both Vitamin D synthesis and in the regulation of body temperature neither are considered barrier functions of the skin.
Which of the following is an important function of the skin? Synthesis of vitamin D Production of carotene Maintenance of acid-base balance Protection against melanin deposits
Synthesis of vitamin D Explanation: A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.
A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown? high mild moderate negligible
high Explanation: This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?
Asymmetrical shape Explanation: Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.
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 Explanation: Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.
A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what? Reynaud disease Central cyanosis Neurofibromatosis Peripheral cyanosis
Peripheral cyanosis Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the patient. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.
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 Explanation: 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.
The nurse should implement which technique when assessing for jaundice in a dark-skinned patient diagnosed with liver disease? asking the client to blink rapidly before assessing the palpebral conjunctiva of the eye assessing the skin covering the client's elbow while applying moderate pressure asking the client to stick out the tongue and assess the presenting surface assessing the client's hard palate with a bright light
assessing the client's hard palate with a bright light Explanation: The nurse should not confuse a normal scleral yellow pigmentation in dark-skinned individuals with jaundice. Rather, the nurse should observe the hard palate with a bright light for jaundice. While it is appropriate to assess for jaundice in the locations identified by the other options, the techniques described are incorrect.
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. Explanation: Freckles are flat, small macules of pigment that appear following sun exposure.
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 notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? heart sounds bowel sounds pulse oximetry body temperature
pulse oximetry Explanation: 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.
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 Explanation: 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.
