common questions- ch.11

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

increased thinness

women comes to the clinic and reports "hair falling out" and butterfly rash. and she says he feels ugly? what nursing diagnosis can the nurse confirm with this data?

ineffective individual coping disturbed body image anxiety

The only layer of the skin that undergoes cell division is the

innermost layer of epidermis

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

keloid formation at the site of an old incision

lesion on the sacrum

osteomyelitis

Squamous cell carcinoma is associated with

overall sun

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding?

papule

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a

papule

where should the nurse check the body for cyanosis?

perioral (around mouth)

When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient?

peripheral artery disease

capillary refill time longer than 2 seconds?

peripheral vascular disease

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 2

which layer as the outermost layer of the epidermis?

stratum corneum

Connecting the skin to underlying structures is/are the

subcutaneous tissue

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 corpis

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?

urticaria/ hives

a client might have shingles. what type of lesion would the nurse assess?

vesicle

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

vitamin deficiency anemia

is an elevated mass with transient borders and no fluid cavity

wheal

use to inspect lesion on the thigh to find fungus?

woods light (ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection)

blue tinged tongue could explain?

advanced lung disease

when a person look older than they really are?

alcoholism

Which of the following terms is used to describe the arrangement of skin lesions?

annular

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

Braden scale for predicting pressure sore risk? what should the nurse check?

clients ability to change position

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?

crushing disease

a nurse inspects and sees the clients bed is greater than 180 degrees. what additional data should the nurse collect?

history of cigarette smoking

Honey colored exudate in a vesicular rash is indicative of

impetigo

woods light is what color for fungal infection?

blue

The apocrine glands are stimulated by what?

emotional stress

pallor could lead to?

fainting

pressure ulcers put in stages?

-intact, firm skin with redness -ulceration involving the dermis -full-thickness skin loss -necrosis with damage to underlying muscle

The nurse expects what change in a client's hair as a result of aging?

Sebaceous glands will secrete less causing hair to be drier.

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding

Vesicle ( serous fluid)

occur after acute illness and eventually grow out.

beau lines

A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify which of the following as an example?

fissure

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

dermis

What is the expected moisture and texture of the skin of a client with hypothyroidism?

dry/ rough

A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?

pityriasis rosea

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next?

preform a random blood sugar test

"pits" in the nails

psoriasis

nail degree greater than 160 degrees, what should the nurse check?

pulse oximetry

oxyhemoglobin play in physiological process?

reduction of red pigment in the arteries

orthodox jew belief?

same sex nurse

a child has developed a rash that is constantly scratching at the abdomen and is serpiginous. the rash is most likely caused by?

scabies

should the nurse anticipate with iron deficiency anemia?

spooning