NUR 230: Ch. 14 - Assessing Skin, Hair, and Nails (PrepU)

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

distribution

A primary function of hair in the nose and eyelashes is to serve as a

filter for dust

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

keloid formation at the site of an old incision

The nails, located on the distal phalanges of the fingers and toes, are composed of

keratinized epidermal cells

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules

Squamous cell carcinoma is associated with

overall amount of sun exposure

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

While assessing a client'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

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

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

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. Age Nutrition Admitting diagnosis Moisture Activity

Activity Moisture Nutrition

The nurse is assessing a dark-skinned client 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 observed Beau's lines. The nurse should ask the client if he has had

a recent illness

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

acne

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

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 preparing to conduct an integumentary assessment will include which interventions when preparing the client for this examination? (Select all that apply.) Assisting the client to put on a gown. Using cotton balls to assess for sensation. Using the mnemonic OLDCART as a guide. Wearing gloves when palpating lesions. Providing adequate drapes.

-Assisting the client to put on a gown -Wearing gloves when palpating lesions -Providing adequate drapes

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. friction created by dragging the skin against bedlinen moisture being allowed to accumulate on the skin pressure that impairs capillary blood flow to the skin restlessly changing position frequently shearing that occurs when sliding down in bed

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

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

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

D

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 Helps make vitamin D in the body Circulates blood throughout the body Largest organ of the body Aids in maintaining body temperature Involved in digestion of food

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

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

UV radiation exposure

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? Actinic lentigines Age Heavy sun exposure Hair color

age

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

allow early identification of neurologic deficits

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

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

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

avoiding sun exposure

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

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 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

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

burning when having a MRI

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

carotene

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.

The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to

chronic discoid lupus erythematosus

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

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

Which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility

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

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

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

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing

domestic abuse

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

The apocrine glands are stimulated by what?

emotional stress

During the integument health history, the nurse asks the client 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

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

An adult male client visits the clinic and tells the nurse he believes he has athlete's foot. The nurse observed that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissure

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

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 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 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 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

hypothyroidsm

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

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

The only layer of the skin that undergoes cell division is the

innermost layer of the epidermis

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 client with a zosteriform rash has a rash that

is distributed along a dermatome

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the earlobe. The nurse should document a

keloid

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

look for information from family and records regarding any problems that may have occurred at least 3 months ago.

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) Vernix Lymphatic vessels Connective tissue Blood vessels Sweat glands

lymphatic vessels blood vessels sweat glands

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

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

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

perioral

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 abdomen.

While assessing an adult client, the nurse observed an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a

plague

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

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

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.

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 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 weeks. 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

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

sclera

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

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?

spoon

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

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

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

the client changes position every 2 hours

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

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries

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

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

touch with the palmar surface of the three middle fingers.

Local redness of the skin warns of impending necrosis.

true

A nurse implements which skin assessment to determine the presence of dehydration in a client?

turgor

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

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

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plan to measure the client's symptomatic lesions and measure the size of the client's

vesicles

A client's skin color depends on melanin and carotene contained in the skin, and the

volume of blood circulating in the dermis