HA CHP 12
The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to:
ANS the eccrine glands. The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are located mainly in the axillae, anogenital area, nipples, and naval and mix with bacterial flora to produce a characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated about 1 mm to 3 mm. What other signs would the nurse expect to find in this patient?
ANS: A red-purple, maculopapular, blotchy rash behind the ears and on the face With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik's spots.
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor?
ANS: An increased loss of elastin and a decrease in subcutaneous fat in the elderly An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.
A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin?
ANS: Ashen, gray, or dull Pallor due to shock (decreased perfusion and vasoconstriction) in black-skinned people will cause the skin to appear ashen, gray, or dull. See Table 12-2.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?
ANS: Basal cell carcinoma Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer, and it grows slowly. This description does not fit acne lesions. See Table 12-11 for descriptions of malignant melanoma and squamous cell carcinoma.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
ANS: Clubbing of the nails Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?
ANS: Color variation Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?
ANS: Dry mucous membranes and cracked lips With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.
The nurse is assessing the skin of a patient who has AIDS and notices multiple patch-like lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:
ANS: Kaposi's sarcoma. Kaposi's sarcoma is a vascular tumor that, in early stages, appears as multiple, patch-like, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash which appears on third or fourth day of illness. Rash appears first behind ears and spreads over face, then over neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles that are elevated with a cavity containing clear fluid, up to 1 cm in size.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
ANS: Lyme disease. Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or papular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy.
The nurse is assessing for inflammation in a dark-skinned person. Which is the best technique?
ANS: Palpate the skin for edema and increased warmth. Because you cannot see inflammation in dark-skinned persons, it is often necessary to palpate the skin for increased warmth, taut or tightly pulled surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.
ANS: Partial thickness skin erosion with loss of epidermis or dermis., Open blister areas have a red-pink wound bed. Stage I pressure ulcers have intact skin that appears red but not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with loss of epidermis or also the dermis, and open blisters have a red-pink wound bed. Stage II pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply.
ANS: Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color, Vesicle: Also known as a friction blister, Nodule: Solid, elevated, hard or soft, larger than 1 cm An elevated, circumscribed lesion filled with turbid fluid (pus) is a pustule. A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid; a papule is solid, elevated, but less than 1 cm.
A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?
ANS: Pitting Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions?
ANS: Severe dehydration Decreased skin turgor is associated with severe dehydration or extreme weight loss.
The nurse is discussing epidermal appendages with a newly graduated nurse. Which of these would be included in the discussion?
ANS: Sweat glands Epidermal appendages include hair, sebaceous glands, sweat glands, and nails.
A 22-year-old woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class?
ANS: Tetracyclines for acne Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
ANS: The importance of sunscreen and avoiding direct sunlight Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
ANS: The newborn's skin is more permeable than that of the adult. The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.
An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of these statements is true about the Inuit sweating tendencies?
ANS: They will sweat more on their faces and less on their trunks and extremities. Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces.
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
ANS: Yellow color of the sclera that extends up to the iris The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice. Do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor in this infant over the:
ANS: abdomen. Test mobility and turgor over the abdomen in an infant. Poor turgor, or "tenting," indicates dehydration or malnutrition. The other areas are not appropriate sites for checking skin turgor in an infant.
The nurse is assessing for clubbing of the fingernails and would expect to find:
ANS: an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:
ANS: carbon monoxide poisoning. A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:
ANS: caused by the complete absence of melanin pigment. Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:
ANS: circulatory status. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are:
ANS: clusters of melanocytes that appear after extensive sun exposure." Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:
ANS: contains sensory receptors. The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatics. It is not replaced every 4 weeks.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cooler examination room temperature. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:
ANS: cutis marmorata. Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity and is a transient mottling in the trunk and extremities in response to cooler room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
ANS: distended veins. Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time. See Table 12-1.
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:
ANS: excess blood in the dilated superficial capillaries. Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.
The nurse is caring for a black child who has been diagnosed with marasmus. The nurse would expect to find the:
ANS: hair to be less kinky and to be a copper-red color. The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color. The other findings are not present with marasmus.
A 13-year old girl is interested in obtaining information about the cause of her acne. The nurse would share with her that acne:
ANS: has no known cause. About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, a contagion, or poor hygiene.
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema would be:
ANS: heart failure. Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.
A patient's mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
ANS: impetigo. Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (chicken pox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out:
ANS: jaundice. Jaundice is exhibited by a yellow color, which indicates rising amounts of bilirubin in the blood. It is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.
The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:
ANS: lesions that run together. Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.
A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
ANS: lichenification. Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges that extends into the dermis, and it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that look crusted, scaly, and warty.
A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
ANS: linea nigra. In pregnancy, skin changes can include striae, linea nigra (a brownish black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or "skin tags" occur more often in the aging adult.
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
ANS: melanocytes. In the aging hair matrix, the number of functioning melanocytes decreases so the hair looks gray or white and feels thin and fine. The other options are not correct.
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
ANS: papule. A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape due to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.
A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:
ANS: peripheral vasoconstriction. A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. See Table 12-1.
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
ANS: refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:
ANS: replaced every 4 weeks. The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.
A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? He probably has:
ANS: seborrheic keratoses, which do not become cancerous. Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are "skin tags" and are not precancerous.
A 42-year-old female patient complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
ANS: senile angiomas. Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk in adults over 30 years old.
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to:
ANS: that confluent and extensive patch of petechiae and ecchymoses on the feet." Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
ANS: the woman could be at increased risk for infection and lesions because of her chronic disease. A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to see a professional for assistance with corn removal.
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting:
ANS: tinea capitis. Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin. It is caused by a fungal infection. Lesions are fluorescent under a Wood light. It is usually seen in children and farmers and is highly contagious. See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.
A mother brings her child in to the clinic for an examination of the scalp and hair. She states that the child has developed some places where there are irregularly shaped patches with broken-off, stub-like hair and she is worried that this could be some form of premature baldness. The nurse tells her that it is:
ANS: trichotillomania and that her child probably has a habit of twirling her hair absentmindedly. Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly-shaped patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It occurs as a child rubs or twirls the area absently while falling asleep, reading, or watching television. See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.
Because hair for humans is no longer needed for protection from cold or trauma, it is called:
ANS: vestigial. Hair is vestigial for humans. It no longer is needed for protection from cold or trauma.
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
ANS: xerosis. Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.
