Chapter 14: Assessing Skin, Hair, and Nails (Review Quesions)

What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips

a. Ashen-gray color of the oral mucous membranes

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

a. vellus

A patient asks the nurse if it is possible to grow new skin. What is the nurse's most appropriate response? a. "Even if new skin growth is required, the melanocytes do not regenerate." b. "The avascular epidermis sheds slowly and is replaced completely every 4 weeks." c. "The outer layer of skin remains the same over the lifetime except for repairing injuries." d. "Epidermal regeneration is impossible because it is avascular."

b. "The avascular epidermis sheds slowly and is replaced completely every 4 weeks."

While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patient's skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter

a. Elevated irregularly shaped areas of edema of variable diameter

A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time? a. Obtain further data now to rule out abuse. b. Remind parents that toddlers are clumsy and may fall, causing bruising. c. Determine if this toddler has a coagulation disorder. d. Recommend further observation at future visits.

a. Obtain further data now to rule out abuse.

A nurse notices a patient's nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes

a. Pale conjunctiva

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 a. hypothyroidism b. hyperthyroidism c. infectious conditions d. hypoparathyroidism

a. hypothyroidism

The only layer of the skin that undergoes cell division is the a. innermost layer of the epidermis b. outermost layer of the epidermis c. innermost layer of the dermis d. outermost layer of the dermis

a. innermost layer of the epidermis

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 a. symptoms of stress b. recent radiation therapy c. pigmentation irregularities d. allergies to certain oods

a. symptoms of stress

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 a. signs of an infectious process b. caused by aging of the skin in older adults c. precancerous lesions d. signs of dermatitis

b. caused by aging of the skin in older adults

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 a. nail beds b. oral mucosa c. sclera d. palms

b. oral mucosa

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 a. stage I b. stage II c. stage II d. stage IV

b. stage II

A client's skin color depends on melanin and carotene contained in the skin, and the a. client's genetic background b. volume of blood circulating in the dermis c. number of lymph vessels near the dermis d. vascularity of the apocrine glands

b. volume of blood circulating in the dermis

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 a. nodules b. bullae c. vesicles d. wheals

c. vesicles

A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder? a. "Your itching is caused by a bacterial infection." b. "Your itching is caused by an allergic reaction." c. "Your itching is caused by a viral infection." d. "Your itching is caused by a fungal infection."

d. "Your itching is caused by a fungal infection."

A toddler patient has a small, slightly raised bright red area on the trunk. The child's mother reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect? a. Vascular nevi b. Purpura c. Ecchymosis d. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

d. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin a. A b. B12 c. C d. D

d. D

During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patient's skin, what finding will confirm the rash? a. Elevated, firm, well-defined lesions less than 1 cm in diameter b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter

d. Flat, well-defined, small lesions less than 1 cm in diameter

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate a. calcium b. vitamin D c. carbohydrates d. fluid intake

d. fluid intake

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a a. cyst b. lichenification c. bulla d. keloid

d. keloid

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 a. basal cell carcinoma b. actinic keratoses c. squamous cell carcinoma d. malignant melanoma

d. malignant melanoma

Connecting the skin to underlying structures is/are the a. sebaceous glands. b. dermis layer. c. papillae. d. subcutaneous tissue.

d. subcutaneous tissue

To assess an adult client's skin turgor, the nurse should: A. Press down on the skin of the feet B. Use the dorsal surfaces of the hands on the clients arms C. Use two fingers to pinch the skin under the clavicle D. Use the finger pads to palpate the skin at the sternum

d. use two fingers to pinch the skin under to clavicle

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

a. macules

Squamous cell carcinoma is associated with a. overall amount of sun exposure b. intermittent exposure to ultraviolet rays c. precursor lesions d. an increase in the rates of melanoma

a. overall amount of sun exposure

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measure 1 cm. The nurse documents this as a a. plaque b. macule c. papule d. patch

a. plaque

What findings does the nurse expect when assessing skin, hair, and nails of a healthy male adult? Select all that apply. a. Transverse depression noticed across nails b. Scalp is bald c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers d. Purpura and ecchymosis are noticed on arms and legs e. Freckles are noted on face, back, arms, and legs f. Skin turgor is elastic

B, E, F

Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply. a. "When did the rash first start?" b. "Do you have a family history of rashes?" c. "What makes the rash worse?" d. "What do you do to make your rash better?" e. "Describe the sensation from the rash, does it burn or itch?" f. "Describe what the rash looked like initially."

A, C, D, E, F

A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura? a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. b. Ecchymosis does not blanch and purpura does blanch. c. Ecchymosis has raised lesions and purpura has flat lesions. d. Ecchymosis is irregularly shaped and purpura is round.

a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter.

When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin

a. Purplish-red pinpoint lesions

A patient has come to the clinic complaining of a "bump" behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? a. Tumor b. Nodule c. Keloid d. Papule

a. Tumor

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. a great degree of cyanosis b. a mild degree of cyanosis c. lupus erythematosus d. hyperthyroidism

a. a great degree of cyanosis

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

a. areola of the breast

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 a. blue b. red c. yellow d. purple

a. blue

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 a. hypoxia b. trauma c. anemia d. infection

a. hypoxia

A nurse notices multiple lesions on the back of a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions? a. As multiple macules on the dorsum of the left hand b. As multiple vesicles on the dorsum of the left hand c. As several patches on the left hand d. As several bullae on the dorsum of the left hand

b. As multiple vesicles on the dorsum of the left hand

A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexor surfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area

b. Hypertrophic scarring extending beyond the original wound edges

A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma? a. Nonblanching lesion b. Irregular border c. Diameter less than 5 mm d. Black color of the lesion

b. Irregular border

A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patient's left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage? a. Stage I b. Stage II c. Stage III d. Stage IV

b. Stage II

A nurse notices that the angle of the patient's proximal nail fold and the nail plate are almost a flat line; about 160 degrees. How does the nurse interpret this finding? a. This patient has chronic pulmonary disease. b. This is an expected finding. c. This is due to stress to the nails. d. This is associated with anemia.

b. This is an expected finding

During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days.

b. Wear protective clothing while in the sun

A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a. Yellowish color in the axilla and groin b. Yellow pigmentation in the sclera c. Very pale skin on the palms d. Ashen-gray color in the oral mucous membranes

b. Yellow pigmentation in the sclera

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears a. greenish b. ashen c. bluish d. olive

b. ashen

A primary function of hair in the nose and eyelashes is to serve as a a. response to cold b. filter for dust c. pigment producer d. response to fright

b. filter to dust

During inspection of a patient's upper back, the nurse notices three small, elevated superficial lesions filled with purulent fluid. How does the nurse document this finding? a. As three cysts on the upper back b. As several bullae on the back c. As three pustules on the upper back d. As three wheals on the upper back

c. As three pustules on the upper back

As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia

c. Clubbing

A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide

c. Color variation

How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color.

c. Inspect the palms and soles for yellowish-green color

What findings does a nurse expect when inspecting and palpating a patient's nails? a. A nail base angle of not more than 90 degrees b. Whitish to clear nails in darker-skinned patients c. Nail surface is smooth and rounded d. Transverse depression running across the nails

c. Nail surface is smooth and rounded

While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? a. Compare its size to the size of a coin. b. Estimate its size to the nearest inch. c. Use a centimeter ruler to measure the lesion. d. Trace the lesion onto a piece of paper.

c. Use a centimeter ruler to measure the lesion

A nurse notices multiple lesions on a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these? a. Macules b. Patches c. Vesicles d. Bullae

c. Vesicles

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had a. chemotherapy b. radiation c. a recent illness d. steroid therapy

c. a recent illness

The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to a. skin cancers than person of European origin b. melanomas if they reside in areas without ozone depletion c. chronic discoid lupus erythematosus d. genetic predisposition to melanomas

c. chronic discoid lupus erythematosus

The nails, located on the distal phalanges of the fingers and toes, are composed of a. ectodermal cells b. endodermal cells c. keratinized epidermal cells d. stratum cells

c. keratinized epidermal cells

A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? a. "This is simple vellus hair and it will decrease in amount over time." b. "Some women in your cultural group normally have dark hair on their faces." c. "This is unusual; female hair distribution should be limited to arms, legs, and pubis." d. "Coarse dark hair could result from hormonal changes such as from menopause."

d. "Coarse dark hair could result from hormonal changes such as from menopause."

A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis

d. As ecchymosis

When performing a skin assessment of an adult patient, the nurse expects what finding? a. Reddened area does not blanch when gentle pressure is applied b. Indentation of the finger remains in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly

d. Return of skin to its original position when pinched up slightly

Hair follicles, sebaceous glands, and sweat glands originate from the a. epidermis b. eccrine glands c. keratinized tissue d. dermis

d. dermis

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing a. leukemia b. diabete mellitus c. melanoma d. domestic abuse

d. domestic abuse

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of a. ulcers b. erosion c. scales d. fissures

d. fissures

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 a. ineffective individual coping related to changes in appearance b. anxiety related to loss of outdoor activities and altered skin appearance c. dry flaking skin and dull dry hair as a result of disease d. risk for ineffective health maintenance related to deficit knowledge of effects of sunlight on skin lesions

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

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's a. abdomen b. arms c. legs d. sclera

d. sclera

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 a. melanoma skin cancers are the most common type of cancers b. African Americans are the least c. usually there are precursor lesions for basal cell carcinomas d. squamous cell carcinomas are most common on body sites with heavy sun exposure

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