Chapter 14: Assessing Skin, Hair and Nails
Which clinical manifestation should the nurse expect to find in a client with edema? a) Prominent blood vessels b) Decreased skin mobility c) Decreased skin turgor d) Mottled skin tones
b) Decreased skin mobility 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.
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? a) Macule b) Papule c) Vesicle d) Nodule
a) Macule 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
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? a) Nose and earlobes b) Around the mouth and lips c) Chest and abdomen d) Fingers and toes
d) Fingers and toes Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.
A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? a) Perioral b) Palms c) Chest d) Facial
a) Perioral The nurse should inspect the oral area to confirm cyanosis in the client. Cyanosis makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival areas. The palm area, facial area, and chest area are not appropriate places to inspect for cyanosis as these areas have thick skin and cannot indicate the presence of blood supply underneath them
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? a) Tinea corporis b) Herpes simplex c) Tinea versicolor d) Multiple nevi
a) 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.
A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? a) To determine the clients risk for pressure ulcers b) To determine the clients risk for herpes zoster c) To determine the clients risk for dehydration d) To determine the clients risk for skin cancer
a) To determine the clients risk for pressure ulcers Older, disabled, or immobile clients who spend long periods of time in one position are at risk for pressure ulcers. Spending long periods of time sitting or lying in one position is not associated with increased risk for skin cancer, dehydration, or herpes zoster.
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? a) Under the breast b) Upper abdomen c) On the neck d) Anterior chest
a) Under the 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
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? a) Flashlight b) Artificial light c) Sunlight d) Wood's light
d) Wood's light 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 nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply. a) Flat b) Change in size c) Itching d) Bleeding of a mole e) Regular borders f) Asymmetrical
f) Asymmetrical b) Change in size c) Itching, d) Bleeding of a mole Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs.
A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin? a) Stratum lucidum b) Stratum corneum c) Epidermis d) Dermis
d) 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. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. a) Helps make vitamin D in the body b) Protects against damage to the body from sunlight c) Aids in maintaining body temperature d) Circulates blood throughout the body e) Involved in digestion of food f) Largest organ of the body
f) Largest organ of the body, b) Protects against damage to the body from sunlight, a) Helps make vitamin D in the body, c) Aids in maintaining body temperature The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.
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? a) Lupus erythematosus b) Iron deficiency anemia c) Basal cell carcinoma d) Cushing's disease
d) Cushing's disease 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.
Which statement by a client about the skin needs validation by the collection of objective data by the nurse? a) "I had a small skin cancer removed about 3 years ago" b) "My feet hurt and are always cold to the touch" c) "My port wine birth mark has not gotten any bigger" d) "I experience itchy and dry skin every winter"
b) "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 patient 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.
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? a) Linear b) Clustered c) Discrete d) Annular
b) Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. 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.
During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse? a) Report the finding to the health care provider b) Document this as a normal finding c) Assess for adequate capillary refill time d) Ask the client about any injury to the nails
b) Document this as a normal finding The nurse should consider the freckle-like pigmentation in the nail beds of the client as a normal finding in dark-skinned people. The variations are due to different amounts of melanin in certain areas. Asking the client about injury to the nail and reporting the finding to the health care provider are not appropriate because there is no pathology involved. Pressing the pigmented area to assess for blood flow is not necessary because there is no evidence of inadequate circulation to the nail beds.
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? a) Avoid asking any questions regarding the client's lifestyle b) Have a nurse who is the same sex as the client examine him c) Allow the client to pray before the examination d) Let the client remained fully dressed for the examination
b) Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.
A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? a) Abnormalities may be a sign of poor hygiene b) Nail problems can be caused by an underlying systemic illness c) Nail problems may affect a persons body image negatively d) Local irritation can cause damage to the nail bed
b) Nail problems can be caused by an underlying systemic illness Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problems because they can be damaging to a person's self-image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.
A nurse implements which skin assessment to determine the presence of dehydration in a client? a) Thickness b) Turgor c) Temperature d) Texture
b) Turgor Assessing for skin turgor will assist the nurse in determining the presence of dehydration. In dehydration, skin turgor will be decreased because the elasticity of the skin is diminished with less moisture. Temperature assesses circulation. Texture refers to smoothness or roughness. Skin is normally thin but can be increased with the presence of calluses or thin in client's with arterial insufficiency.
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. a) Risk for Infection b) Ineffective Individual Coping c) Disturbed Body Image d) Anxiety e) Impaired Skin Integrity
c) Disturbed Body Image, b) Ineffective Individual Coping, d) Anxiety This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection
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 a) Assess the client for changes in sensation due to vascular problems b) Suggest that the client use antiperspirant products c) Document the findings in the client's record as normal d) Monitor the client for additional findings of cystic fibrosis
c) 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 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? a) Viral Exanthum b) Herpes zoster c) Impetigo d) Psoriasis
c) Impetigo Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral infection.
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data? a) Altered Tissue Perfusion b) Risk for Imbalanced Body Temperature c) Risk for Impaired Skin Integrity d) Disturbed Body Image
c) Risk for Impaired Skin Integrity The nursing diagnosis of Risk for Impaired Skin Integrity can be confirmed because of the presence of thickened toenails that may cause damage to the epidermis of the skin on the lower extremities. There is no data to support the presence for Risks of Imbalanced Body Temperature or Altered Tissue Perfusion. The client has not mentioned any criteria to support a Disturbed Body Image.
How should the nurse palpate the skin of a client to assess its texture? a) Rub the dorsal surface of the hand over the skin b) Press the fingertips to the skin surface c) Touch with the palmar surface of the three middle fingers. d) Pinch and roll the skin between the fingers
c) Touch with the palmar surface of the three middle fingers. 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.
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? a) Cyst b) Papule c) Vesicle d) Wheal
c) Vesicle The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.
The nurse recognizes that which client is at greatest risk for the development of skin cancer? a) 45-year-old female with 10 year history of cigarette smoking b) 28-year-old Caucasian male who works in a paper mill c) 15-year-old female with facial freckles d) 55-year-old male who lived in California for 20 years
d) 55-year-old male who lived in California for 20 years The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red h air. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.
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? a) Color is uniform b) Borders well demarcated c) Diameter less than 1/8 of an inch d) Asymmetrical shape
d) Asymmetrical shape 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 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? a) Unbroken but red in color b) Exposure of subcutaneous tissue and muscle c) Ulceration resembling a crater d) Broken with the presence of a blister
d) Broken with the presence of a blister 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.
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? a) Environmental exposure to chemicals b) Treatment for fungal infections in the past c) Onset of iron deficiency anemia d) History of cigarette smoking
d) History of cigarette smoking An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.
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? a) Liver disease b) Diabetes mellitus c) Crohns disease d) Hypothyroidism
d) 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. Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.
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? a) Carotene b) Capillary blood flow c) Collagen d) Melanin
d) Melanin The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.
Which technique should the nurse use to properly assess a client's skin turgor? a) Palpate the skin on the sternum to determine its flexibility b) Palpate the skin around the umbilicus to assess for intactness c) Pinch the skin on the abdomen and observe for color changes d) Pinch the skin over the clavicle and observe its return to the original shape
d) Pinch the skin over the clavicle and observe its return to the original shape The nurse should assess skin turgor by pinching the skin over the clavicle and determining how quickly the skin returns to its original shape. Skin turgor is assessed over the clavicle and not on the abdomen. Palpation is not a technique used to assess for skin turgor.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? a) Vitiligo, hirsutism, vitamin deficiency b) Alopecia, dermatitis, chemotherapy c) Eczema, melanoma, herpes zoster d) Psoriasis, fungal infections, trauma
d) 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.
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? a) Dry and flaky skin in the winter months b) Small lesion left forearm for one month c) Denies any skin color changes d) Skin warm and dry to the touch
d) Skin warm and dry to the touch 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.
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? a) Clubbing b) Beau's lines c) Paronychia d) Spooning
d) 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.
A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply. a) Have the client stand for the entire examination b) Have the client remove his toupee c) Wear gloves when palpating lesions d) Use sunlight, if possible, to inspect the skin e) Keep the room door closed f) Ask the client to remove only his shirt
d) Use sunlight, if possible, to inspect the skin, b) Have the client remove his toupee, c) Wear gloves when palpating lesions, e) Keep the room door closed To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on an examination gown. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. The client may remain in a sitting position for most of the examination. If available, sunlight is best for inspecting the skin. Wear gloves when palpating any lesions because you may be exposed to drainage. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.
