NUR 201 - Jensen Ch. 11
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?
Sebum production
A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?
Stratum corneum
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.
Recommended protective measures to avoid skin cancer include which of the following?
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?
Braden scale
A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red colour remains. What should the nurse do?
Consider admitting the client to the hospital.
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 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."
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?
Excessive collagen formation
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
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 tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?
Peripheral cyanosis
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.
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?
Risk for Impaired Skin Integrity
A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?
The client had a recent infestation
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 radiation 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
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
What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.
a cancerous skin lesion located on the back presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation
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.
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis.
A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
divot
A client is diagnosed with a stage IV pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
divot
The apocrine glands are stimulated by what?
emotional stress
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
fainting
A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate
fluid intake.
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 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.
When documenting that a patient has freckles, the appropriate term to use is
macules
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
macules.
A client has an elevated mass with transient borders on the forearm. Which diagram should the nurse use to explain this mass to the client?
oil filled looking ass
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?"
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?
"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."
A patient asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this patient'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."
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
Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?
19 to 23
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?
Impetigo
For which client condition would the nurse most likely expect a capillary refill time longer than 2 seconds?
Peripheral vascular disease
In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?
Peripheral vascular disease
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
Which technique should the nurse use to properly assess a client's skin turgor?
Pinch the skin over the clavicle and observe its return to the original shape
A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?
Pityriasis rosea
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?
Pressure ulcer
While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?
Purpuric
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
When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)
Red or light hair Freckles Immunosuppression
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 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
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
Spooning
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
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Stage II
When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition?
Sun exposure
A client is scheduled for an MRI of the left knee. What assessment finding could cause the client to experience discomfort while having the diagnostic test?
Tattoo on the left lower leg
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?
Tenting indicates dehydration
Which of the following findings related to hair would the nurse most likely assess in an older adult female client?
Terminal hair growth on chin
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 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 is consistently incontinent of urine.
A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?
The client's ability to change position
The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?
The cyanosis may be a result of a prolonged period of exposure to the cold.
A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?
The elderly should bathe or shower only every 2 to 3 days
A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following?
Thin
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 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
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 client admitted with dehydration would typically have a decrease in skin turgor.
True
A decrease in oxyhemoglobin will result in documentation of pallor.
True
A patient admitted with dehydration would typically have a decrease in skin turgor.
True
Local redness of the skin warns of impending necrosis.
True
The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?
Vasoconstriction
A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?
Vesicle
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?
Vesicle
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
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?
Vitiligo
The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
Vitiligo
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal
A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment?
When palpating lesions on the client's skin
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light
The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?
a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution
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
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 apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast.
The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.
bottom portion
The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C?
color
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 patient with a zosteriform rash has a rash that
is distributed along a dermatome
The nails, located on the distal phalanges of the fingers and toes, are composed of
keratinized epidermal cells.
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 client 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
papule
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
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
papule.
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
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?
Are you allergic to foods, medications, or other substances?
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?
Asymmetric, irregular borders
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.
Asymmetrical Change in size Itching Bleeding of a mole
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
Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?
Can be caused by an underlying systemic illness
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
Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?
Discrete
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.
Disturbed Body Image Ineffective Individual Coping Anxiety
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
A female client is noted to have excessive hair on her face and chest. The nurse plans further evaluation of which body system?
Endocrine
The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?
Endocrine
During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
Existence of systemic diseases that have skin manifestations
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
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
When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient?
He has peripheral artery disease
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
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
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
Short, pale, and fine hair that is present over much of the body is termed
vellus.
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 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.
A patient 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 patient 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 client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for finding of which disease process?
Diabetes mellitus
What role does oxyhemoglobin play in the physiological process that results in pallor?
the reduction of red pigment in the arteries
The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?
trichotillomania
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
underarms
To assess an adult client's skin turgor, the nurse should
use two fingers to pinch the skin under the clavicle.
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
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
Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what?
Acne
A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client?
Age
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
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
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 behavior 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?
Alopecia areata
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?
Alopecia areata
Which of the following terms is used to describe the arrangement of skin lesions?
Annular
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
D.
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?
Cushing's disease
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?
Cushing's disease
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
What does examination of the skin involve? Select all that apply.
Inspection Palpation
A client's fingernails are noted to be very thin and concave. The nurse knows the client needs medical follow-up for further assessment of which condition?
Iron deficiency anemia
During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?
Iron deficiency anemia
Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?
It is likely to be related to her lupus.
Which of the following assessment findings most likely constitutes a secondary skin lesion?
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.
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 nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?
Macule
A client has sustained burns over 50% of the body. When planning care for this client, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.)
Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes
After teaching a group of students about the structure and function of the skin, the instructor determines that the teaching was successful when the students identify which of the following as responsible for variations in skin color?
Melanin
A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?
Melasma generally resolves postpartum
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 nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?
Monthly
A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?
Nail problems can be caused by an underlying systemic illness
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
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?
Osteomyelitis
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next?
Perform a random blood sugar test.
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
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 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.
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 ||.
Connecting the skin to underlying structures is/are the
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
symptoms of stress.
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."
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 "ABCD" characteristic of malignant melanoma?
Asymmetrical shape
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
Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse knows this may be caused by what complication?
Bacterial infection
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution
When preparing to examine a client's skin, which of the following would be most important for the nurse to do?
Expose only the body part that is being examined
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 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
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?
Risks of sun exposure
A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?
Skin tags are common benign skin lesions
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
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 been abused.
Which of the following statements most accurately conveys an aspect of the anatomy and physiology of the skin?
The skin is composed of an epidermis, dermis, and subcutaneous tissue.
A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?
There is a nonblanching reddened area on the client's coccyx region.
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 notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?
hypoxia
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.
A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
pimple looking ass
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 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 skin lesions.
