Jensen's Health Assessment 3rd Ed. | Chapter 11

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?

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

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

Annular

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

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

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."

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

notched border diameter great than 6 cm asymmetry

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years Rationale: The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red hair. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis?

Perioral

The nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined.

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.

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

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Petechiae

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

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

A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis?

Tinea versicolor Rationale: This is a typical description of tinea versicolor. The information that the client is sweating more also helps support this diagnosis, because tinea is a fungal infection and promoted by moisture.

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

UV radiation exposure

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

assessing the client's hard palate with a bright light

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.