Coursepoint chapter 14

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

Allow early identification of neurologic deficits - it does reveal overhydration

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 A = asymmetry B = border C = color D = diameter E = evolving

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

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

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? Assess the client for changes in sensation due to vascular problems Document the findings in the client's record as normal

Document the findings in the client's record as normal

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

False it is a vesicle

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

Fissures

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

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

____ is an oily substance that lubricates hair and skin and reduces water loss through the skin.

Sebum

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

Carotene is responsible for yellow color of the skin

TRUE

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The client exhibits no signs or symptoms of infection

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The client may have been abused

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

A decrease in oxyhemoglobin will result in documentation of pallor

True

Spoon nails are a characteristic feature of iron deficiency anemia.

True

A nurse implements which skin assessment to determine the presence of dehydration in a client?

Turgor

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

UV exposure

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?

Under the breast

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

Underarms

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

Vellus hair

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

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast entire skin surface

areola of the breast

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

dermis

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

destruction of hair follicles located in the dermis layer

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

domestic abuse

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

fainting

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

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

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

stage II

Short, pale, and fine hair that is present over much of the body is termed

vellus

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

carotene

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 stage I= skin is inflamed Stage II = skin is broken Stage III = subcutaneous fat tissue Stage IV = see muscle or bone

Perspiration increases with aging because sweat gland activity increases.

False

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

Stage III

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

Turgor

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

Wood's light

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

ashen

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

hypothyroidism

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

osteomyelitis

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?

pulse oximetry

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

use two fingers to pinch the skin under the clavicle

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

Allow early identification of neurologic deficits

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral cyanosis

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

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

acne

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area

Linear crack in the skin that may extend to the dermis and may be painful is called a _______.

fissure

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

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?

Dermis

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

The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing?

Skin turgor

Pressure areas in stage I involve epidermis, dermis, and subcutaneous tissues.

false

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 cushing disease - Hirsutism: hair on chin, chest, and face

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 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?

cushings disease

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 moist and smooth

dry and rough

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

palmar surfaces

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

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on

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

Distribution

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client

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 or hives crust - ulceration cyst - encapsulated fluid filled or semi solid located in subcutaneous tissue Papule - slightly raised, varied in color (insect bite, razor burn) Pustule/Abscess - cellular debris or puss filled fluid in vesicle Ulcer - lesion itself goes into dermal layer Vesicle - ver circumsized, elevated, surface blister Wheal/hive - can be fluid filled, typically red, urticarial, insect bites

Which of the following assessment findings most likely constitutes a secondary skin lesion? facial lesions associated with herpes simplex keloid formation at the site of an old incision

keloid formation at the site of an old incision