integumentary prep u HA

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Artificial light Flashlight Wood's light Sunlight

Wood's light

A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Lupus erythematosus Basal cell carcinoma Iron deficiency anemia Cushing's disease

cushing's disease

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a wheal papule bulla pustule

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 macule. papule. patch. plaque.

papule.

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? alcoholism Marfans syndrome Parkinsons disease Cushings syndrome

alcoholism

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? Hepatic failure Respiratory failure Renal failure Cardiovascular failure

Renal failure

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

Keloid formation at the site of an old incision

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 nodules. vesicles. wheals. bullae.

vesicles

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 vesicles. nodules. bullae. wheals.

vesicles

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 legs. arms. sclera. abdomen.

sclera

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? "Have you ever been assessed for diabetes?" "Has anyone in your family ever been diagnosed with skin cancer?" "What dietary supplements do you usually take?" "Do you take steroid medications on a regular basis?"

"Do you take steroid medications on a regular basis?"

The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled skin. During health promotion, the nurse should focus education on what topic? Susceptibility to bruising Management of dry skin Risks of fungal infections Risks of sun exposure

Risks of sun exposure

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? Repeated sunburns in childhood may explain the presence of some of your moles. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "These are considered a normal age-related change in the skin." "It means you have skin cancer and need to have them removed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."

"These are considered a normal age-related change in the skin."

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 9 11 15 13

15

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1intact, firm skin with redness 3necrosis with damage to underlying muscle 4full-thickness skin loss 2ulceration involving the dermis

1intact, firm skin with redness 3ulceration involving the dermis 4full-thickness skin loss 2necrosis with damage to underlying muscle

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? 4 1 3 2

3

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 55-year-old male who lived in California for 20 years 15-year-old female with facial freckles 45-year-old female with 10 year history of cigarette smoking

55-year-old male who lived in California for 20 years

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Arrangement Colour Type Distribution

Distribution

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Alcoholism Cushings syndrome Marfans syndrome Parkinsons disease

Alcoholism

The student nurse learns that examining the skin can do all of the following except? Allow early identification of potentially cancerous lesions Identify physical abuse Allow early identification of neurologic deficits Reveal overhydration

Allow early identification of neurologic deficits

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behaviour at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? Tinea capitis Alopecia areata Traction alopecia Trichotillomania

Alopecia areata

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? "Does anyone else in your family have a rash like this?" "What have you been doing to control the itching?" Are you allergic to foods, medications, or other substances? "Have you ever had a rash like this before?"

Are you allergic to foods, medications, or other substances?

Recommended protective measures to avoid skin cancer include which of the following? Knowing signs of skin cancer Performing monthly skin self-examinations Seeking biannual examination by a clinician after age 40 years Avoiding sun exposure

Avoiding sun exposure

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? Norton scale Newton scale Braden scale Head-to-toe assessment

Braden scale

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

D.

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

Dermis

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? Moist and rough Moist and smooth Dry and smooth Dry and rough

Dry and rough

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? Allow the client to pray before the examination Have a nurse who is the same sex as the client examine him Avoid asking any questions regarding the client's lifestyle Let the client remained fully dressed for the examination

Have a nurse who is the same sex as the client examine him

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? Herpes zoster Psoriasis Impetigo Viral Exanthum

Impetigo

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 Move on to next body system Document the statement Ask further questions

Inspect the area

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

Keloid formation at the site of an old incision

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. Protects against damage to the body from sunlight Aids in maintaining body temperature Involved in digestion of food Largest organ of the body Circulates blood throughout the body Helps make vitamin D in the body

Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Oral mucosa Palms Sclera Nail beds

Oral mucosa

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Seborrheic keratosis Cutaneous horn Pressure ulcer Cherry angioma

Pressure ulcer

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? Pityriasis rosea Tinea infection Psoriasis Eczema

Psoriasis

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart? Contact dermatitis Eczema Seborrhea Psoriasis

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Eczema, melanoma, herpes zoster Vitiligo, hirsutism, vitamin deficiency Psoriasis, fungal infections, trauma Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient? Pustular acne Bullous impetigo Cystic acne Chickenpox

Pustular acne

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Sweat glands Squamous cells Subcutaneous tissue Sebum production

Sebum production

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? Transverse white lines in the nails Beau's lines White spots, or leukonychia, on the nail surfaces Small pits in the surfaces of the nails

Small pits in the surfaces of the nails

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client adheres to a vegetarian diet. The client is consistently incontinent of urine. The client has a full-time caregiver. The client has a surgical diagnosis.

The client is consistently incontinent of urine.

The nurse is admitting a 79-year-old man for outpatient surgery. The patient 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 patient may have peripheral vascular disease. The patient may have a cognitive deficit. The patient is elderly. The patient may have been abused.

The patient may have been abused.

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? Herpes simplex Multiple nevi Tinea corporis Tinea versicolor

Tinea corporis

What is the most important focus area for the integumentary system? Washing the face and hands UV radiation exposure Moles with defined borders smaller than 6 mm Chemical exposure

UV radiation exposure

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect? Dermatomyositis Addison disease Vitiligo Tinea versicolor

Vitiligo

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

dermis.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) asymmetry pink color notched border diameter great than 6 cm

notched border diameter great than 6 cm asymmetry

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 sclera. nail beds. palms. oral mucosa.

oral mucosa.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by scabies lice allergies ticks

scabies

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

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

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 IV. stage II. stage III. stage I.

stage II.

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

subcutaneous tissue.

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 pigmentation irregularities. allergies to certain foods. symptoms of stress. recent radiation therapy.

symptoms of stress.