NURS 314: Skin, Hair, and Nails
During the health history, the examiner learns that the patient had a red macular rash of the axillae and regional lymphadenopathy due to a tick bite. The examiner also discovers that patient did not undergo any treatment, and the rash disappeared after a month. What additional questions should the examiner ask the patient? Select all that apply.
"Do you have joint pain?" "Are you uncommonly tired?" "Have you lost your appetite?" Rationale: The presence of red macular rash at the axillae and regional lymphadenopathy due to the tick bite indicates that the patient is in the first stage of Lyme disease (LD). Usually the rashes fade away after 4 weeks. However, if left untreated, the patient may have disseminated disease along with anorexia, fever, chills, joint, or muscles aches. Therefore, the examiner would ask the patient about the presence of fatigue, weakness, fever and chills, and joint or muscle pains. The patient with LD lacks appetite and becomes anorexic; LD does not cause frequent urination. Therefore, the examiner would not ask the patient about weight gain or frequent urination.
The nurse is evaluating patient understanding of instructions for self- skin examination. Which statement by the patient would indicate a need for further clarification?
"I need to especially concentrate on my arms and face since dysplastic nevi are more common in these sun-exposed areas." Rationale: Dysplastic nevi are more common on the shoulders and back, not the arms and face. Thus, this statement would require clarification. The patient is correct to begin the self- skin examination with the face and scalp and then proceed downward, to see rather than feel for early signs of changes in moles, and to assess areas where moles are rarely found such as the buttocks, scalp, and breast.
A 32-year-old female patient presents to the provider complaining of recent hair growth on the face, neck, and lower abdomen. She asks the nurse why this is occurring. Which explanation by the nurse provides the best response?
"It can be caused by high androgen levels, which can occur due to many causes." Rationale: Hirsutism in women may be caused by high androgen levels or by hair follicles, which are more sensitive to androgen. This can be a result of many causes including genetic, physiologic, endocrine, drug-related, and systemic disorders. It is not a normal occurrence for a young to middle-aged female. It is not a result of low estrogen levels or an autoimmune issue.
The nursing instructor is teaching a class on the layers of the skin. Which statement, if made by a student, indicates the need for further teaching?
"Keratin provides a brown tone to the skin." Rationale: The melanocytes intercalated along the basal cell layer produce the pigment melanin, which gives brown tones to the skin. Keratin has no function in skin pigmentation. The epidermis, or the outer layer, is made of tough fibrous protein called keratin. The skin of the palms and soles is thicker due to work and weight bearing. The amount of melanin depends on genetic, hormonal, and environmental influences. Therefore, it varies considerably from person to person.
A nursing instructor is lecturing on nail physiology. Which statement by a nursing student indicates a need for further teaching?
"Ridges on the nail plates disappear with age." Rationale: Fine longitudinal ridges on the nail bed become prominent with age. Nails take their pink color from the underlying nail bed of the vascular epithelial cells. The lunula rather than the matrix is the white, opaque, crescent area at the proximal end of the nail. The cuticle covers the nail matrix.
An instructor is teaching nursing students about skin turgor. Which statement by the student indicates effective learning?
"Skin turgor can be used to assess hydration status." Rationale: Turgor is defined as the ability of the skin to return to its normal place after being stretched. It is affected by extreme weight loss, because the subcutaneous fat deposition is depleted. Skin turgor is diminished with age because of the natural aging process. A loss of turgor is associated with dehydration rather than a fluid overload. Because turgor is related to skin, bony prominences have no relevance to skin turgor.
During a routine examination of an infant, the parent points out a large, round, light brown patch on the infant's arm. The parent worries this could be a skin disease. What is the appropriate response by the examiner?
"That is a cafe au lait spot." Rationale: A large round or oval patch of light brown pigmentation present at birth is known as a cafe au lait spot. The name means "coffee with milk" because of its color. It is a normal finding in infants. Bruising is a soft-tissue injury that follows a rapid, painful, or breech birth. The Mongolian spot is a common variation of hyperpigmentation in black, Asian, American Indian, and Hispanic newborns. It is a blue-black to purple macular area generally seen at the sacrum or buttocks. Six or more cafe au lait spots, each more than 1.5 cm in diameter, are diagnostic of neurofibromatosis, an inherited neurocutaneous disease. In this case, the child has only one cafe au lait spot, so it is not neurofibromatosis
The nurse is completing an assessment on an infant being evaluated for dehydration after repeated bouts of vomiting for the past 24 hours. The nurse evaluates tissue turgor and notes that it takes 4 seconds to return to normal after the pinch. Additionally, the infant is crying, but no tears are noted and the fontanels are sunken. Which degree of dehydration would the nurse document for this infant?
9-10% loss of body weight Rationale: When estimating dehydration by pinching a fold of the abdominal skin between the index finger and thumb, the nurse can estimate the percentage of body weight lost by the amount of time it takes the pinched skin to return to normal after the pinch. If the return takes 3-4 seconds, estimated body weight lost is 9-10%. If it takes 2-3 seconds, 5-8% loss of body weight is estimated. If it takes less than 2 seconds, less than 5% loss of body weight is estimated. If it takes more than 4 seconds, more than 10% loss of body weight is estimated.
The patient presents to the clinic with complaints of redness, swelling, and pain around the right thumb nail. With pressure, purulent discharge is released around the nail. The examiner anticipates the patient will be prescribed antibiotics for which condition?
Acute paronychia Rationale: Red, tender, and swollen nails along with inflammation along the base of the nail, or where it meets the skin on the sides, indicate that the patient has paronychia. It is caused either by a bacterial or fungal infection. However, chronic paronychia is usually caused by a fungal infection. Scabies is caused by scabies mites and it is associated with linear or curved elevated burrows on the fingers, web spaces of the hands, and the wrists. The patient with scabies has severe itching. If the patient's nails have deep grooves resulting in a depression of the nail bed, then it indicates that the patient has beau line. The presence of reddish-brown line streaks on the finger and toenails indicates that the patient has splinter hemorrhages. It may be caused either due to a sports injury or trauma
While assessing a Caucasian patient, the examiner observes that the patient's skin is white in color. Which condition may cause this skin tone?
Albinism Rationale Albinism is an inherited disorder characterized by the complete absence of melanin that colors the skin, hair, and eyes. In a Caucasian, the skin color changes to whitish pink, while in a person with darker skin it appears white and creamy colored. Hyperemia is the increased blood flow through the capillaries due to vasodilation. In this condition, the skin color changes to red or bright pink, rather than whitish-pink. Polycythemia is the increased red blood cell count that results in reddish-blue colored skin. Addison disease is characterized by cortisol deficiency, which stimulates the production of melanin and results in dark or tanned skin.
During a skin assessment, the nurse notes that a patient has a mole with irregular edges. This finding reflects which aspect using the ABCDE acronym?
Borders Rationale According to the ABCDE acronym, irregular edges would reflect the B, which stands for borders. Irregular edges do not reflect color, diameter, or asymmetry.
The examiner is assessing a patient in the clinic and notes several lesions. The ones still intact appear to be vesicles that are greater than 1 cm in diameter. The patient reports that he had several more in the same area but they ruptured when he touched them lightly. Which term should the examiner use to document this finding?
Bullae Rationale: A bulla is a type of primary lesion that appears superficially in the epidermal layer of the skin. It is a vesicle that is greater than 1 cm in diameter. Because it is thin walled, it ruptures easily. A wheal is a superficial, transient, erythematous, slightly irregularly shaped lesion caused by edema. A papule, a solid, elevated, circumscribed primary lesion less than 1 cm diameter, appears due to superficial thickening of the epidermal layer of the skin. A macule is a flat and circumscribed primary lesion of less than 1 cm in diameter.
While assessing an infant, the examiner finds that the infant has yellowish-orange discoloration of the skin on the palms and the soles. Upon interacting with the child's parents, the examiner learns that infant will only eat carrots, sweet potatoes, and butternut squash. Which condition does the examiner suspect in this child?
Carotenemia Rationale: Carotene is the precursor of vitamin A. An intake of an excess amount of food rich in vitamin A may increase carotene levels in the blood, resulting in yellowish-orange discoloration of the skin. This is called carotenemia. Acrocyanosis is associated with bluish discoloration of the skin, which is caused by hypothermia. It may disappear upon increasing the temperature of the skin by rubbing the patient's palms and soles. Cutis marmorata is associated with the presence of reddish or bluish patterns or mottling of the skin on exposure to cooler temperatures. Hemangioma is associated with the presence of a reddish-blue spongy mass of blood vessels in the brain.
While assessing an infant , the examiner finds that the infant has yellowish-orange discoloration of the skin on the palms and the soles. Upon interacting with the child's parents, the examiner learns that infant will only eat carrots, sweet potatoes. and butternut squash. Which condition does the examiner suspect in this child?
Carotenemia Rationale: Carotene is a precursor of vitamin A. An intake of an excess amount of food rich in vitamin A may increase carotene levels in the blood, resulting in yellowish-orange discoloration of the skin. This is called carotenemia. Acrocyanosis is associated with bluish discoloration of the skin, which is caused by hypothermia. It may disappear upon increasing the temperature of the skin by rubbing the patient's palms and soles. Cutis marmorata is associated with the presence of reddish or bluish patterns or mottling of the skin on exposure to cooler temperature. Hemangioma is associated with the presence of a reddish-blue spongy mass of blood vessels in the brain.
A 50-year-old patient tells the examiner, "I have bright red, raised dots on my torso, which have grown in size and number as I got older." The examiner would provide education to the patient about which skin condition?
Cherry angiomas Rationale: Cherry angioma is a skin bruise characterized by small, red lesions on the trunk. These lesions will increase in number and size with age, and are insignificant. Anasarca, toxic alopecia, and alopecia areata are not associated with bright red spots on the trunk. Anasarca is associated with the presence of bilateral edema all over the body. Toxic alopecia is associated with chemotherapy-induced hair loss that results in patchy balding. Alopecia areata is associated with sudden and severe hair loss that results in a round or oval balding patch on the scalp.
After examining the nails of a patient, the examiner concludes that the patient has chronic iron deficiency anemia. Which finding supports the examiner's conclusion?
Concave shaped, spoon-like nails Rationale: The patient with chronic iron deficiency anemia may have an inadequate supply of blood to the center of the nail that results in improper texture and shape of the nails. Therefore, presence of concave shaped, spoon-like nails indicates iron deficiency anemia. Iron deficiency anemia is not associated with the elevation of inner edge of the nails, tender inflammation of the nail folds, or the depression across the nail extending to the nail bed. The patient with late clubbing may have elevation of inner edge of nails due to increased platelet-derived growth factor caused by an underlying condition like heart or lung disease. The patient with paronychia has tender inflammation of the nail folds due to bacterial or fungal infection. The patient with a beau line has depression across the nail extending to the nail bed due to acute illness or trauma.
The nurse is completing a skin assessment for a patient being admitted to the long-term care center. During the assessment, the nurse notes several pigmented, raised, warty lesions on the patient's trunk. Which priority action should the nurse take based upon these findings?
Contact an experienced practitioner to make an appointment for further evaluation. Rationale: Pigmented, raised, warty lesions on the patient's trunk are seborrheic keratosis, which are similar to other growths such as nevi or actinic keratosis. These growths may have malignant potential, and the patient should be referred to an experienced provider for differential diagnosis. These lesions are not generally reflective of allergies from soaps or lotions. The lesions should be documented, but this is not the priority action. These lesions do not generally occur secondary to anticoagulant or antiplatelet use
While caring for a newborn, the examiner notices that the newborn's skin is reddish-blue and mottled, likely due to the cool room temperature. The examiner increases the room temperature and swaddles the newborn in a blanket. After a few hours, the examiner finds that the reddish-blue discoloration has subsided. The examiner understands the patient had which condition?
Cutis marmorata Rationale: When a newborn has reddish-blue discoloration of skin due to cooler temperatures, it indicates that the newborn has cutis marmorata. If a newborn has persistent symptoms of cutis marmorata, it indicates that the newborn has impaired thermoregulation. It may be caused by genetic abnormalities, such as Down syndrome. Acrocyanosis is the bluish discoloration of the hands and feet, but not of the entire body, of the newborn, and it disappears within a few hours. Carotenemia is the yellowish-orange discoloration of the skin due to increased carotene levels in the body of the newborn. If the newborn has persistent symptoms of cyanosis, such as bluish discoloration of the skin, then it indicates that the newborn has a risk of congenital heart disease.
Which layer of the skin includes the melanocytes which synthesize melanin?
Epidermis Rationale: The epidermis is the outermost layer of the skin, which is composed of several layers, including the stratum basale, where the melanocytes are located. They are not located in the dermis, hypodermis, or connective tissue.
A patient reports a tingling sensation on the mouth and painful ulcers on the tongue and oral mucosa. The health care provider instructs the examiner to collect the sore tissue for culture. Which microorganism does the examiner expect to find in the patient's tissue specimens?
Herpes simplex virus Rationale: The presence of painful ulcers on the tongue and oral mucosa indicates that the patient has acute gingivostomatitis. Herpes simplex virus infection causes tingling sensation, increases skin sensitivity, and causes acute gingivostomatitis. Tinea corporis, Tinea versicolor, and varicella zoster virus do not cause acute gingivostomatitis. Tinea corporis is caused by a fungal infection resulting in hyperpigmentation and circular lesions. Tinea versicolor causes a fungal infection that is associated with the presence of round pink, tan, or whitish patches on the neck, trunk, and upper arms. The varicella zoster virus causes chickenpox . Chickenpox is characterized by the presence of small, tight vesicles that first appear on the trunk and then spread to the face, arms, and legs, but not to the palms of the hands and soles of the feet.
While assessing a 16-year-old female patient, the examiner finds that the patient has excess hair on her face, legs, hands, and chest. Which term does the examiner use to document this finding?
Hirsutism Rationale The presence of excess hair on the face, legs, hands, and chest indicates that the female patient has hirsutism. This condition is caused by improper functioning of the endocrine glands or a metabolic dysfunction that results in high testosterone levels in females. Folliculitis is a superficial inflammatory infection of hair follicles. It is commonly found in men and is associated with hair loss on the scalp. Trichotillomania is a self-induced hair loss that is caused by excessive plucking, pulling, or tugging of the hair. It is commonly seen in patients with psychiatric disorders. Traumatic alopecia is caused by hair styling such as tight braiding or trauma caused by hair rollers, resulting in high pressure on the scalp.
The patient presents to an urgent care clinic complaining of itching and peeling of the feet. Upon assessment, the examiner notes scale-like lesions on the bottom of the feet and between the toes. The examiner scrapes the affected skin, treats the sample with potassium hydroxide, and views it under a microscope. What does the examiner anticipate seeing under the microscope?
Hyphae Rationale: The patient's symptoms are indicative of athlete's foot, which is caused by tinea pedis. A skin scraping that is treated with potassium hydroxide (which dissolves skin and other cells) and viewed under a microscope will show presence of hyphae. Clusters of cocci are indicative of staphylococcus bacteria, which are certainly present in the skin scraping but will not be visible after treatment with potassium hydroxide. Amoebae are single-celled organisms that can alter its own shape; it is generally found in bodies of water. Rodlike bacteria with flagellae might be Heliobacter pylori, which causes peptic ulcer disease and would be found in the stomach, not on the feet.
The nurse is staging a pressure ulcer in the sacral area for an older patient recently admitted from home. Assessment of the wound includes visible subcutaneous fat, slough in the center of the wound, and scant purulent exudate and tunneling (4 cm) at the 12 o'clock position. The nurse would classify this as which stage of ulcer?
III Rationale: A stage III wound is characterized by full thickness tissue loss with visible subcutaneous tissue. Bone, tendon, and muscle are not exposed. Slough and tunneling may both be present. Stage II pressure ulcers are shallow with only partial thickness loss of dermis without slough. Stage IV pressure ulcers are full thickness tissue losses with exposed bone, tendon, or muscle. Unstageable pressure ulcers have full thickness tissue loss, but are unstageable due to coverage of the base of the wound by slough.
The examiner is assessing a child who has thick honey-colored crusts on the body. The child's mother tells the examiner, "Last week I found similar blisters on a boy's hand with whom my child was playing in the park." The examiner anticipates the child will be diagnosed with which infection?
Impetigo Rationale: Impetigo is a bacterial infection that is associated with honey-colored crusts on the body. It is highly contagious and can spread through direct contact. Therefore, the examiner concludes that the child has impetigo. Intertrigo is a fungal infection associated with scalding red, moist patches near the genitals. If the child has erythematous papules and vesicles along with the lesions on the scalp, forehead, cheeks, and forearms, the examiner would expect that the child has atopic dermatitis. If the child has reddish purple rashes on the skin and Koplik spots in the mouth, then the examiner would expect that the child has measles (rubeola).
The nurse is completing a skin assessment on an older adult. Which changes due to aging might the nurse expect to find upon assessment? Select all that apply.
Increased epidermal permeability Collagen loss and decreased elasticity Decreased sebaceous and sweat gland activity Rationale: As adults age, epidermal permeability increases, collagen loss and decreased elasticity occur, and sebaceous and sweat gland activity decreases. Subcutaneous tissue decreases. Coarse terminal hair appears in the pubic area during adolescence.
Well caring for a pregnant patient, the examiner finds that the patient has redness in the palms. Which condition may cause is finding?
Increased estrogen level Rationale: during pregnancy, estrogen levels increase, resulting in hyperestrogenemia. Hi estrogen levels cause vasodilation and increase blood circulation, which result in palmar erythema. An increase in bilirubin levels may cause yellow is discoloration of the sclera, not redness in the palms. An increase in the carotene levels may cause yellowish orange discoloration of the palms, soles, and forehead. An increase in white blood cells is an indication of an infection, which is associated with an elevated body temperature.
While assessing an infant, the examiner finds that the patient has a yellowish discoloration of the skin, sclera, hard palate, and the mucous membranes. What laboratory finding would the examiner expect?
Increased serum bilirubin level Rationale The presence of a yellowish discoloration of the skin, sclera, hard palate, and mucous membranes indicates that the patient has jaundice. Jaundice is a disorder that is characterized by impaired liver functioning and high serum bilirubin levels, which would show up in the patient's lab reports. An increase in the red blood cells may cause polycythemia, which results in erythema, not yellowish discoloration of the skin. A decrease in thyroxine levels may cause hypothyroidism, not jaundice. A decrease in white blood cells may increase the risk of infection, but does not result in jaundice.
While assessing a patient, the examiner finds the presence of a yellow- orange tinge in the palms and soles, but not in the sclera. Which laboratory finding would the examiner expect?
Increased serum carotene level Rationale: The presence of yellow-orange tinge in the palms and soles indicates that the patient has carotenemia. Carotenemia is caused by the impaired digestion, absorption, and metabolism of carotene-rich foods. This increases the serum carotene levels. An increase in the red blood cells may cause polycythemia, which results in erythema, not yellow-orange discoloration of the skin. An increase in bilirubin levels results in jaundice and a yellow-orange tinge of the sclera and skin. An increase in the serum thyroxine levels may cause hyperthyroidism, but will not result in a yellow-orange tinge of the patient's skin.
While caring for a 3-year-old child, the examiner finds a raised, bright red area of about 3 cm in diameter on the child's scalp that does not blanch on pressure. The lesion is expected to disappear in 2 to 4 years. Which condition does the examiner suspect?
Infantile hemangioma Rationale: Immature hemangioma, also known as strawberry hemangioma, is seen in newborns and usually disappears when children reach 5 to 7 years of age. The presence of a raised bright red area on the scalp with a diameter of 2 to 3 cm is indicative of a strawberry mark, or immature hemangioma. It is caused by the presence of immature blood capillaries at birth. Telangiectasia is associated with vasodilation of the blood vessels, which results in permanent enlargement or dilation of the blood vessels. Nevus flammeus, also known as port-wine stain, is a condition that is characterized by the presence of a dark red, large, flat, macular patch on the scalp or the face. This macular patch intensifies when exposed to extreme temperatures. Cavernous hemangioma is associated with the presence of an irregular-shaped, reddish-blue, spongy mass of blood vessels at birth.
A pregnant patient at 32 weeks gestation complains of generalized itching, which is more severe on the palms of her hands. Based upon this complaint, which other finding should the nurse assess for in this patient?
Jaundice Rationale: Itching during pregnancy can be caused by impaired flow of bile from the liver, particularly if the itching is more severe on the palms of the hands or soles of the feet. Thus, the nurse should also assess the patient for jaundice. This finding would not indicate the need to assess for melasma, telangiectasis, or molluscum fibrosum gravidarum, which can all occur during pregnancy.
The examiner is caring for a patient with acquired immunodeficiency syndrome (AIDS). The examiner notes soft, bluish purple lesions. The patient denies pain in these lesions. Suspicion of which condition should be reported to the provider?
Kaposi sarcoma Rationale: Kaposi sarcoma (KS) is a vascular tumor in patients with AIDS. Soft, painless, bluish purple lesions are characteristic of KS. It tends to occur in immunocompromised patients such as those with human immunodeficiency virus (HIV). Scalp ringworm is indicated by the sudden appearance of a sharply circumscribed, round or oval balding patch. Thick, yellow-to-white, greasy, adherent scales with mild erythema on the scalp and forehead are the key symptoms of seborrheic dermatitis. Head lice are insects that cause intense itching of the scalp.
While caring for a pregnant patient, the examiner observes that the patient has a dark brown line up and down on the midline of the abdomen. Which term should the examiner use to document this finding?
Linea nigra Rationale: Hormonal changes occur during pregnancy, resulting in pigmentation changes in the skin. The presence of a dark brown line on the abdomen indicates that the patient has linea nigra. It is caused by an increase in melanin levels in the body. Chloasma is characterized by the presence of dark brown irregular patches on the face. It is due to the increase in the melanin levels, resulting in hyperpigmentation. Vascular spiders are associated with the presence of lesions with tiny red centers that spread to the face, neck, upper chest, and arms. They are caused by an increase in estrogen levels. Striae gravidarum are linear stretch marks that appear on the thighs or abdomen typically after delivery or in the third trimester of pregnancy.
The nurse is asked to complete a thorough skin assessment on a toddler with suspected physical abuse. Which physical findings does the nurse know may indicate physical abuse? Select all that apply.
Lip lacerations Patchy bald spots Bruising over soft tissue Rationale:Lip lacerations can reflect forced feeding, patchy bald spots may indicate repeated hair pulling, and bruising over soft tissue may be associated with injury in toddlers, which usually occurs over bony prominences. These findings can all be evidence of physical abuse. Presence of lesions around the mouth and erythematous ulcerations on lower extremities are not necessarily indicative of physical abuse.
While assessing the skin of an adult patient, the examiner finds a birthmark that is 8 mm in diameter on the back with irregular borders. Upon questioning the patient, the examiner learns this birthmark is larger and darker than the patient remembers. These assessment findings prompt the examiner to report which possible condition to the patient's provider for further examination?
Malignant melanoma Rationale: Birthmarks are brown in color, look like moles, and may have a diameter up to 6 mm. Birthmarks with diameters of more than 6 mm that are growing larger and darker with irregular borders are warning signs of malignant melanoma and further assessment is needed. Lichenification is characterized by intense itching, which eventually thickens the skin and results in tightly packed papules, not moles. An increase in melanin levels does not result in red raised dots on the trunk, and will not cause cherry angiomas. A cherry angioma is caused by bruising of the skin; it is not due to the presence of moles. Localized erythema associated with peripheral arterial insufficiency may result in Raynaud's disease.
While assessing a 1-week-old infant, the examiner finds that the infant has white papules on the cheeks, forehead, and across the nose and the chin. Which term does the examiner use to document this finding?
Milia Rationale: The obstruction of sebaceous glands causes white papules on the cheeks, forehead, nose, and chin. They are called "milia" and they disappear within a week. Acrocyanosis is a bluish discoloration of the hands and feet and disappears within a few hours. Vernix caseosa is a thick cheesy substance made of sebum and epithelial cells. It is present at birth and protects the infant from infection and heat. Mongolian spots are large bluish patches on the skin that resemble bruises. Therefore, the symptoms do not indicate Mongolian spots.
Which patient would the nurse suspect of having chronic obstructive pulmonary disease (COPD) based upon findings of the nail assessment?
Nail yellowish in color, nail base angle 175 degrees, boggy nail base Rationale: COPD can result in several nail changes, including a yellowish discoloration, a nail base angle greater than 160 degrees, and a boggy nail base. Thus, the nurse would suspect that this patient may have COPD. Variations of pink coloring of the nail bed, a nail base angle of 160 degrees, and a firm nail base are all normal findings. A thickened or thinned nail, separation of the nail base, curvature of the nail plate, and longitudinal ribbing are all abnormal findings, which can reflect a variety of conditions but not necessarily COPD.
The examiner is performing an admission assessment on a 65-year-old patient. Upon assessment of the toenails, the examiner notes the right great toe has yellowing of the distal nail plate and debris under the distal nail that is elevating the nail from the nail bed. However, there is no pitting of the nail. Which condition does the examiner report to the provider for further examination?
Onychomycosis Rationale: Onychomycosis is a slow, persistent fungal infection of the fingernails that causes change in the color and thickness of the nail plate. The nail plate also loosens as debris pushes the nail away from the nail bed. These same symptoms can be present in psoriasis, but psoriasis also has pitting of the nail where onychomycosis does not. A beau line is a transverse furrow or groove in the nail bed. It occurs due to some trauma that temporarily impairs the formation of the nails. A splinter hemorrhage is associated with the presence of reddish brown linear steaks on the finger and toenails. It is caused by trauma or sports injuries.
While examining the skin of a patient, the examiner finds silver mica- like scales on the patient's elbows and knees. The examiner anticipates the patient will be diagnosed with which condition?
Psoriasis Rationale Psoriasis is an autoimmune disease characterized by the presence of dry, silver mica- like scales on the elbows and knees. The scales are formed by the shedding of excess keratin cells. Cheilosis, ecchymosis, and candidiasis are not associated with silver mica- like scales. Cheilosis is associated with scaly lips and fissures at the corners of the mouth. Ecchymosis is associated with a purplish patch resulting from extravasation of blood into the skin. It appears more than 3 mm in diameter. Candidiasis is associated with the presence of scalding red, moist patches with sharply demarcated borders.
A patient presents to the dermatologist with complaints of recent skin issues that have developed over the past few weeks. The patient has been stressed recently and wonders if the issues are related to the stress. Upon assessment, the nurse notes dry, scaly papules and plaques on the patient's scalp, elbows, and shins. The patient reports that at night the itching keeps the patient awake. The patient has tried applying lotion, which does not seem to help. Which skin abnormality does the nurse suspect the patient may be experiencing?
Psoriasis Rationale: Psoriasis is characterized by well-circumscribed, dry, silvery, scaling papules and plaques, which are commonly found on the back, buttocks, extensor surfaces of the extremities, and scalp. The assessment data does not support identification as pityriasis rosea, eczematous dermatitis, or tinea (dermatophytosis).
During an assessment, the examiner observes that the nail bases of the patient feel soft and spongy on palpitation. On further assessment, the examiner finds out that the angle of the nail base is 180 degrees. What possible condition can the examiner anticipate?
Pulmonary disease Rationale: A soft, spongy nail base at an angle of 180 degrees indicates clubbing of the nails. Clubbing of nails is an indication of congenital cyanotic heart disease, lung cancer, and pulmonary disease. Persistent dirty nails are an indication of poor self-care and poor personal hygiene. Jagged, bitten nails or traumatized nail folds suggest a nervous picking habit. Thick and ridged nails indicate arterial insufficiency.
While assessing a child with impetigo, the examiner finds honey- colored, crustlike lesions on the child's chin. Which other type of lesion does the examiner expect to find in the child?
Pustules Rationale:Impetigo is a highly contagious bacterial infection that is common in children. It characterized by the presence of primary and secondary lesions. Honey-colored, crustlike lesions are the secondary lesions, whereas pustules are the primary lesions associated with impetigo. These lesions are circumscribed, elevated, and filled with pus. Impetigo is not associated with scales, papules, or macules. Patients with psoriasis or eczema may have scales, which are secondary skin lesions. Patients with measles or scarlet fever may have macules as the primary skin lesions. Patients with elevated nevi or warts may have papules, which are primary skin lesions.
Which homeostatic processes are performed by the skin? Select all that apply.
Regulates body temperature Prevents invasion of microorganisms Assists in the production of vitamin D Rationale: Ultraviolet rays of the sun fall on the skin, and the sunlight transforms cholesterol into vitamin D. Skin helps in thermoregulation by adjusting heat through the sweat glands via subcutaneous fat. The skin acts as a mechanical barrier that protects the body against peripheral invasions of microorganisms. The hormones insulin and glucagon regulate blood glucose. The acid-base balance is regulated inside the body, and the skin does not participate in it.
A 4-year-old patient presents to the pediatrician's office with a cough and stuffy nose; the patient's mother reports a low-grade fever. The examiner notes a papular rash on the patient's face, chest, and arms. There are no lesions in the patient's mouth, but the throat appears inflamed. The patient's father tells the examiner that the rash started yesterday and was originally flat, red, and only on the patient's face and chest. The examiner activates airborne isolation precautions based on suspicion of which condition?
Rubella Rationale: Rubella, or German measles, is a highly contagious viral infection that is associated with mild respiratory symptoms and a sore throat as well as the presence of reddish- purple rashes on the face, neck, and arms. Initially, the rash is macular on the face and chest and quickly turns into a papular rash that spreads to the extremities. Although the infection is relatively mild in healthy patients with intact immune systems, it can be dangerous to immunocompromised individuals and developing fetuses in the first trimester. Koplik spots are small, bluish lesions present inside the mouth that indicate the presence of measles. Measles, or rubeola, is a viral infection characterized by the presence of reddish purple rashes on the skin and Koplik spots in the mouth. Because the patient does not have Koplik spots in the mouth, the examiner does not report that the patient has measles. Impetigo and intertrigo are not associated with Koplik spots or neck lymphadenopathy. Impetigo is a bacterial infection characterized with honey- colored crusts on the skin. Intertrigo is a fungal infection caused by Candida.
The examiner suspects jaundice in a dark-skinned patient. What locations of the body should the examiner assess to confirm this diagnosis? Select all that apply.
Sclera Buccal mucosa Under the tongue Rationale: In dark-skinned people, normal pigmentation tends to hide the color change caused by jaundice. Therefore, it is advisable to look for changes in pigmentation in the places that have the least pigmentation. The areas under the tongue, the buccal mucosa, and the sclera are ideal places to confirm changes in pigmentation. The lips and nail beds show some color change. However, these vary from person to person, so these places are not advisable for a confirmatory diagnosis.
A patient complains of dryness of the scalp, forehead, face, and chin. What can the examiner conclude from these symptoms?
Sebaceous secretion has been disrupted Rationale: Sebum secreted from the sebaceous gland oils and lubricates the skin and hair and forms an emulsion with water that retards water loss from the skin. It is abundantly present on the scalp, forehead, face, and chin. Therefore, dryness of the scalp, forehead, face, and chin indicates disruption of sebaceous secretion. Melanocytes secrete melanin that controls skin color. Keratin has no function in preventing skin dryness. The epidermis, or the outer layer, is made of tough fibrous protein called keratin. Adipose tissues are fat deposits interspersed below the skin; they help in thermoregulation.
The nurse is reviewing risk factors for melanoma with a patient who presented to the provider's office for an overall skin assessment. Which risk factors would the nurse include in the discussion? Select all that apply.
Skin type I or II First-degree relative with melanoma History of severe blistering sunburns History of using indoor tanning devices Rationale: Skin type I or II, a first-degree relative with melanoma, history of severe blistering sunburns, and a history of using indoor tanning devices are all risk factors for developing melanoma. When completing a skin assessment, questions about the use of antibiotics and steroids and travel to developing countries should be asked but are not considered risk factors for developing melanoma.
What sign or symptom would the examiner look for while assessing a patient who has chronic liver disease?
Spider angioma Rationale-Spider angioma is a classic sign of chronic liver disease. Spider angioma is a fiery red, star-shaped marking with a solid circular end. It generally develops on the face, neck, or chest. Venous lake is a purple dilation of the venules and capillaries in a star-shaped, linear, or flaring pattern. Venous lake is associated with varicose veins. Ecchymosis is a purpuric lesion resulting from the extravasation of blood into the skin and is not related to chronic liver disease. Telangiectasia is a type of vascular lesion caused by permanently enlarged and dilated blood vessels that are visible on the skin surface.
While assessing an adolescent, the examiner finds reddish-brown linear streaks on the toenails. Upon interacting, the examiner learns that the adolescent was injured 2 days ago while playing soccer. Which term does the examiner use to document this finding?
Splinter hemorrhages Rationale: The presence of reddish-brown linear streaks on the nails indicates that the adolescent has inflammation of the nails, which is caused by damage to the nail bed and the blood capillaries. This condition is known as splinter hemorrhages, and it is commonly caused by sport injuries or trauma. Scabies is associated with the presence of linear or curved elevated burrows on the fingers and the wrist. It is an infection caused by the scabies mite. Beau line is characterized by the presence of a transverse furrow or groove on the nail that extends to the nail bed. It is caused by an acute illness or toxic reaction. Acute paronychia is caused by a bacterial infection. It is associated with the presence of pus and throbbing pain in the nails.
The examiner is performing an admission assessment on an elderly bedridden patient who was brought to the hospital from a long-term care facility. The examiner notes a pressure ulcer on the patient's sacrum. Upon further assessment, the examiner finds that the bone is visible through the ulcer, and there is black necrotic tissue around the wound. How would the examiner stage this pressure ulcer?
Stage IV Rationale: The term pressure ulcer refers to a localized injury caused by complete or partial obstruction of blood flow to the soft tissue at the site of an injury. Immobility increases the pressure on the bones, which are in contact with the bed, and may result in the development of the pressure ulcer. Based on the extent of the damage caused to the tissues, pressure ulcers are classified into four types. In the stage IV pressure ulcer, all skin layers are damaged and the wound extends into supporting tissue. Thus, the examiner can see the bone and the black necrotic tissue around it. A stage I pressure ulcer is characterized by localized redness. A stage II pressure ulcer is characterized by loss of epidermis and dermis. A stage III pressure ulcer is associated with damage to the subcutaneous tissues. In this stage, the examiner can visualize subcutaneous fat from the wound, but not the bone.
The 8-year-old patient presents to the clinic with a rash on the dorsal arms that is red, weeping, and intensely itchy. Reviewing the patient's chart, the examiner notes a history of asthma and allergic rhinitis. The examiner anticipates the patient will be diagnosed with which condition?
The patient has atopic dermatitis Rationale: Atopic dermatitis is the inflammation of skin due to allergy. Erythema is the redness of the skin due to dilation of blood vessels. The presence of erythematic, weeping lesions, such as sores on the arms and the elbows in response to an allergic reaction, indicates that the patient has atopic dermatitis. Impetigo, intertrigo, and chickenpox are not associated with an allergic reaction. Impetigo is a bacterial infection associated with honey-colored crusts on the skin. Intertrigo is a fungal infection associated with scalding red, moist patches on the skin. Chickenpox (varicella) is a viral infection caused by the varicella zoster virus. It is associated with small, tight vesicles on the trunk that spread to the face, arms, and legs, and is also highly contagious. It does not occur due to allergic reaction.
After assessing a patient who has undergone an appendectomy, the examiner documents the presence of a keloid at the surgical site. Which finding enabled the examiner to reach this conclusion?
The patient has excess scar tissue at the site of the surgery. Rationale: The presence of excessive fibrous tissue over the skin at the site of the injury or surgery indicates that the patient has a keloid scar. The presence of depressed skin at the site of the surgery indicates that the patient has an atopic scar. It is caused by the loss of tissue. Crusts are the thick dried exudates left after the bursting of vesicles. The presence of tightly packed papules at the site of the surgery indicates that the patient has lichenification. It is caused by prolonged or intense scratching.
While assessing a patient, the examiner finds that the patient has raised thick areas of pigmentation, which are crusted, dark, and greasy in appearance. Upon further assessment, the examiner finds that these patches of pigmentation are noncancerous. What does the examiner interpret from these findings?
The patient has seborrheic keratosis Rationale: The presence of scaly and crusted pigmented areas on the skin is indicative of keratoses. In a patient with seborrheic keratosis, the sweat glands are swollen and, therefore, the patient has dark, greasy, and "stuck on" pigmentation. These patches are noncancerous. Senile lentigines are noncancerous skin pigmentations that are associated with the presence of small, flat, brown macules on the areas of the skin that are exposed to sun. Actinic keratosis is a malignant skin disorder that is associated with hyperpigmentation and may result in squamous cell carcinoma. Acrochordon is associated with excessive growth of normal skin cells that are nonmalignant. Acrochordons have characteristic polyp-like extensions on the cheeks and neck. All the others conditions are not associated with inflammation of the sweat glands and, therefore, do not show dark, greasy, and crusted areas.
While assessing a patient, the examiner finds that the patient has raised thick areas of pigmentation, which are crusted, dark, and greasy in appearance. Upon further assessment, the examiner finds that these patches of pigmentation are noncancerous. What does the examiner interpret from these findings?
The patient has seborrheic keratosis Rationale: The presence of scaly and crusted pigmented areas on the skin is indicative of keratoses. In a patient with seborrheic keratosis, the sweat glands are swollen and, therefore, the patient has dark, greasy, and "stuck on" pigmentation. These patches are noncancerous. Senile lentigines are noncancerous skin pigmentations that are associated with the presence of small, flat, brown macules on the areas of the skin that are exposed to sun. Actinic keratosis is a malignant skin disorder that is associated with hyperpigmentation and may result in squamous cell carcinoma. Acrochordon is associated with excessive growth of normal skin cells that are nonmalignant. Acrochordons have characteristic polyp-like extensions on the cheeks and neck. All the others conditions are not associated with inflammation of the sweat glands and, therefore, do not show dark, greasy, and crusted areas.
After assessing a patient the examiner concludes that the patient has folliculitis. Which finding in the patient enabled the examiner to reach this conclusion?
The patient has whiteheads with an erythematous base on the neck. Rationale: The presence of whiteheads with hair and an erythematous base on the neck indicates that the patient has folliculitis. Folliculitis is an infection, which is associated with a superficial inflammation of hair follicles. The presence of an oval patch of hair loss along the hairline is indicative of traumatic alopecia. If a patient pulls his or her hair during psychotic episodes, it indicates that the patient has trichotillomania. The presence of thick, yellow scales on the forehead and the scalp indicates that the patient has seborrheic dermatitis.
During an assessment, a patient reports that a mole on his arm has recently changed color. The patient also complains of itching and light bleeding of the mole. What can the examiner suspect from the symptoms?
The patient may have malignant melanoma Rationale: A rapidly changing lesion and development of itching, burning, or bleeding in a mole may be an indication of malignant melanoma. A normal birthmark is tan to brown and devoid of any itching sensation. Freckles are tiny, flat macules of brown melanin pigment that occur in skin that is frequently exposed to the sun. Vitiligo is an acquired condition characterized by the complete absence of the melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, and body folds and around orifices.
While assessing a dark-skinned patient, the examiner believes the patient has erythema due to polycythemia. What would the examiner check in order to confirm the presence of polycythemia in this patient?
The presence of reddish lips Rationale: Erythema is redness of the skin; some causes of erythema include hyperemia, polycythemia or increased red blood cell count, and venous stasis. It is difficult to identify erythema in a patient with dark skin because the symptoms of erythema are well concealed by excessive pigmentation. Erythema caused by polycythemia may result in redness of the lips due to the increase in the number of red blood cells. The examiner would check for the presence of redness in the lips because the lips may not have pigmentation in dark-skinned patients. Hyperemia is the increased blood flow through the capillaries due to vasodilation, which results in a purplish tinge on the skin. It is difficult to identify a purplish tinge of the skin in patients with naturally darker skin. However, a purplish tinge is indicative of erythema due to hyperemia, but not due to polycythemia. The presence of a yellow sclera in the limbus is indicative of jaundice, not erythema. The presence of yellow sclera near the limbus is indicative of erythema caused by carbon monoxide poisoning. Carbon monoxide poisoning is characterized by presence of cherry-red colored nails.
While caring for a patient with an anxiety disorder, the examiner finds that the patient has severe self-induced hair loss. Which term does the examiner use to document this condition?
Trichotillomania Rationale: A patient with an anxiety disorder may unconsciously twist and pull hair unconsciously. This results in hair loss and the patient's hair may appear as irregular patches on the scalp. This condition is known as trichotillomania. Folliculitis, pediculosis capitis, and seborrheic dermatitis are not associated with a personality disorder. Folliculitis is a superficial inflammation of hair that occurs after shaving and results in whiteheads with visible hair. Pediculosis capitis, or head lice, is an infection that causes severe itching in the head. Seborrheic dermatitis is characterized by the presence of a thick, yellow, greasy erythema on the scalp.
While caring for a newborn, the examiner observes a white cheesy substance on the neonate's body. Which term does the examiner use to document this finding?
Vernix caseosa Rationale: Vernix caseosa is a thick, cheesy substance made of sebum and epithelial cells. It is present at birth and protects the newborn from heat and prevents skin infections. Lanugo is the fine downy hair that is present in the newborn for the first few months after birth. Vellus hair is the soft thin hair that grows all over the body except the genitals, palms, and soles of feet. It appears after the first few months when lanugo disappears. Terminal hair is dark thick hair that grows on scalp and eyebrows.
While assessing a patient, the examiner finds that the patient has symmetric bilateral, patchy, milk-white spots on the face. Suspicion of which condition does the examiner report to the provider for further examination?
Vitiligo Rationale: The presence of symmetric bilateral, patchy, milk-white spots indicates that the patient has vitiligo. It is caused by destruction of melanocytes that result in depigmentation of the skin. Albinism is caused by a complete absence of melanin, which results in whitish-pink, tan, or cream discoloration of the skin. Cyanosis is caused by an ischemic condition, which results in low oxygen levels in the blood. It is associated with a bluish discoloration of the skin. Erythema is caused by infection or inflammation that results in bright red discoloration of the skin, not patchy milk-white spots.
While caring for a patient with chronic inflammation, the examiner finds that the inner edge of patient's nails is elevated, and the distal part of the fingers looks round, wider, and shiny. Which terms does the examiner use to document this finding?
late clubbing Rationale: Late clubbing refers to the change in appearance of nails due to underlying conditions like chronic lung inflammation. In this condition, the pulmonary circulation impaired, resulting in deposition of the fragmented platelets in the fingertips. As a result, platelet derived growth factor is released, which promotes the growth of the nails. Thus, the middle inner edge of the nail is elevated with clubbing. A beau line is associated with a groove across the nail that extends to the nail bed. It is caused by acute illness or local trauma. Onycholysis is a fungal infection, which is associated with greenish discoloration of the nail bed. Chronic paronychia is a fungal infection associated with the presence of breaks in the cuticle. It is most commonly caused by doing "wet" work.
