NUR 1068 Health Assessment Ch 14- Assessing skin, hair, and nails

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 inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

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.

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

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

use two fingers to pinch the skin under the clavicle.

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

vellus.

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

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

A nurse notices that a client's nails on the right hand have separated from the nail bed and appear yellow. What could be a cause of this condition? Select all that apply.

Fungal infections Trauma Warts

Local redness of the skin warns of impending necrosis.

True

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

Wood's light

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue.

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

drier.

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

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

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

Keloid formation at the site of an old incision

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

Acne

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

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.

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

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

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma.

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

Palmar surfaces

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

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

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

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

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?

Reassure the mother that this is normal.

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?

Signs and symptoms of melanoma

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch"

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

Melanin

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?

Small pits in the surfaces of the nails

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness.

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.

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

15

The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash?

Allergic reaction

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

Allow early identification of neurologic deficits

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

Annular

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

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

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

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.

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

Carotene

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

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

D.

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

Distribution

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

Document this as a normal finding

The RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed

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

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

Pustular acne

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

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 corporis

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast.

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

ashen.

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

dermis.

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

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

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage II.

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.

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

underarms

The nurse is providing discharge teaching to a client who underwent a hip fracture repair. The nurse should instruct the client to report which findings that indicate surgical site infection? (Select all that apply.)

Pain at incision site Tenderness at incision site Redness over hip area Surgical site warm to touch

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?

3

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

Dermis

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

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

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?

Document the findings in the client's record as normal

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

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.

Evaluate the client's outcomes Modify nursing interventions

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

Osteomyelitis

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.

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.

Moisture Activity Nutrition

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm.

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?

Psoriasis

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

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.

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

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

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

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 mm 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

oral mucosa.

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:

symptoms of stress