PrepU- Ch14

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.

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

Underarms

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

Fingers and toes

A 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

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

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

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

Palmar surfaces

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

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

macules.

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.

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

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

vellus.

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

ashen

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

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

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

Carotene

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

fainting

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?

4

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

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

Acne

When inspecting the hair, what would the nurse note? (Select all that apply.)

Color Condition of hair shaft Hair shafts that are shiny

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?

2

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 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

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 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 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

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