Nursing health assessment and promotion: Chapter 11: Skin, Hair, and Nails

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 comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

"It takes about 6 months to totally replace a fingernail." Explanation:

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."

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 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

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?

67-year-old White female

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

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 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

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

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

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

Distribution

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

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

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 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 tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area

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

Keloid formation at the site of an old incision

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Location Distribution pattern Elevation Color

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 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

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?

Petechiae

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

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

Reassure the mother that this is normal

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 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 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

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

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.

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

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 non-blanching reddened area on the client's coccyx region.

The nurse is performing a skin assessment on a client and notes the presence of a rash in a butterfly pattern across the bridge of the nose and cheeks. Which consideration should the nurse take into account based on this finding?

This is characteristic of systemic lupus erythematosus (SLE)

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

UV radiation exposure

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?

Vesicle

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.

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

areola of the breast.

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.

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

fainting

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

folliculitis

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?

hypoxia

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

keratinized epidermal cells.

When documenting that a client has freckles, the appropriate term to use is

macules

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.

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

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

stage II.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II.

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

use two fingers to pinch the skin under the clavicle.

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

vellus