Prepu: Chapter 64: Introduction to the Integumentary System (Donnelly-Moreno & Moseley, 2022)

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis Explanation: The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lies directly beneath the epidermis.

Production of melanin is controlled by a hormone secreted by which gland?

Hypothalamus Explanation: The production of melanin is influenced by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone, among other factors. Production of melanin is not controlled by the thyroid, adrenal, or parathyroid gland.

A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client's fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?

Psoriasis Explanation: Pitted surface of the nails is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD.

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull. Explanation: Shock due to decreased perfusion and vasoconstriction is indicated in dark skin as an ashen gray, dull appearance.

Which characteristics would be expected in a "within normal limit" skin assessment? Select all that apply.

intact warm dry Explanation: A typical "within normal limit" skin assessment includes descriptions such as intact, warm, dry.

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles Explanation: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions.

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?

Conduction Explanation: Three major physical processes are involved in loss of heat from the body to the environment. The first process—radiation—is the transfer of heat to another object of lower temperature situated at a distance. The second process—conduction—is the transfer of heat from the body to a cooler object in contact with it. The third process—convection, which consists of movement of warm air molecules away from the body—is the transfer of heat by conduction to the air surrounding the body.

While assessing a dark-skinned client at the clinic, the nurse notes the presence of patchy, milky-white spots. The nurse knows that this finding is characteristic of what diagnosis?

Vitiligo Explanation: With cyanosis, nail beds are dusky. With polycythemia, the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or "external tan," is associated with Addison disease. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky white spots, often symmetric bilaterally.

A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response?

"Earwax is made by glands in your ears." Explanation: Earwax or cerumen is made by specialized apocrine glands called ceruminous glands, which are found in the external ear where they produce cerumen or wax. There is no evidence that the amount of earwax lessens with aging. Flushing the ears with water when showering will not reduce the amount of cerumen produced. There is no evidence that cerumen increases when an infection is present.

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by the parents for an outbreak of urticaria. What would be the most appropriate question to ask this client's parents?

"Has your child eaten any new foods today?" Explanation: Foods can cause skin reactions, especially in children. In most cases, this is a more plausible cause of urticaria than bathing, contact with other children, or soil-borne pathogens.

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?" Explanation: The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.

A client is concerned about finding a few strands of hair on a pillow after sleeping and additional strands on the brush when styling the hair. Which response will the nurse make regarding the client's concern?

"There are approximately 100 strands of hair lost per day." Explanation: Throughout a person's life, hair follicles undergo continuous cycles of growth, transition, and rest. The rate of growth varies and the hair follicle can be in a growth, involution, or resting phase. Approximately 5% to 10% of hair is in the resting phase when shedding occurs. A person will typically shed approximately 100 scalp hairs each day. Losing hair does not mean the hair follicle is dying. Finding hair strands on a pillow or brush is not unusual and does not need to be evaluated. Most people who lose hair do not have an undiagnosed illness.

The nurse is assessing a client in the clinic and observes a fine skin rash over the arms and trunk. What question is a priority that the nurse asks related to the rash?

"What medication are you taking?" Explanation: The nurse should always suspect a drug allergy whenever the client has a skin rash. Most, but not all, drug allergies cause minor skin rashes and hives. Be aware that clients may describe a drug's side effect, or a coincidental experience during the time when taking a particular drug, as a drug allergy. The other options are questions that may be asked in the interview, but the priority is the medication.

During a routine appointment, a young client presents a piece of hand drawn artwork to the doctor. The client has a "lump of skin" on the longest digit the right hand—the client's coloring hand. What is the pathophysiology behind this lump? Select all that apply.

*accelerated epidermal cell production *callus Explanation: Areas of the skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin.

A client with human immune deficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what situation?

A reduction in the client's CD4 count Explanation: Cutaneous signs may be the first manifestation of human immune deficiency virus (HIV), appearing in more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with low CD4 counts and may become very atypical in immunocompromised people. Viral load increases, not decreases, as the disease progresses. Antiretrovirals are not noted to cause cutaneous changes and viruses do not change an individual's allergy status.

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?

An insect bite Explanation: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next?

Assess the characteristics of the lesion. Explanation: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empirical basis.

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client?

Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Explanation: Actinic ketatosis, sometimes referred to as solar keratosis, is a plaque skin condition caused by long-term exposure to ultraviolet light. A plaque is a group of coalesced papules with a flat top. Of the choices presented, the best advice the nurse can give the client is to instruct them about preventive measures to avoid direct sun or ultraviolet light. This could prevent future breakouts since this condition can reoccur. This condition develops over a number of years and typically affects clients over 40, who work outdoors frequently, sunbath, or tan. This condition is not directly related to stress. Changing career fields is not be a practical or necessary intervention for this client. While the condition could resolve itself, the client should seek medical advice as some studies suggest a precancerous component. Dietary restrictions, limiting caffeine and alcohol do not have a direct correlation related to this condition. The most common surgical intervention is cryotherapy.

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client? You Selected: Recommend the client speaks with a health care provider about currettage which is the most common treatment.

Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Explanation: Actinic ketatosis, sometimes referred to as solar keratosis, is a plaque skin condition caused by long-term exposure to ultraviolet light. A plaque is a group of coalesced papules with a flat top. Of the choices presented, the best advice the nurse can give the client is to instruct them about preventive measures to avoid direct sun or ultraviolet light. This could prevent future breakouts since this condition can reoccur. This condition develops over a number of years and typically affects clients over 40, who work outdoors frequently, sunbath, or tan. This condition is not directly related to stress. Changing career fields is not be a practical or necessary intervention for this client. While the condition could resolve itself, the client should seek medical advice as some studies suggest a precancerous component. Dietary restrictions, limiting caffeine and alcohol do not have a direct correlation related to this condition. The most common surgical intervention is cryotherapy.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau line Explanation: A Beau line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line Explanation: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?

Biopsy Explanation: Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scrapings are used to diagnose spores and hyphae. A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster. A patch test is used to identify substances to which the client has developed an allergy.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

Bronze Explanation: Patients diagnosed with Addison's disease have a bronzed appearance, an "external tan." Yellowish skin is noted in the patient diagnosed with jaundice. Patients with renal failure may have a gray or orange-green cast to the skin.

The nurse is assessing a client who was a victim of a house fire. Which finding indicates to the nurse that the client may have carbon monoxide poisoning?

Cherry red lips Explanation: Skin color changes can occur with different health conditions. Cherry red lips indicate carbon monoxide poisoning. A ruddy blue face is associated with polycythemia. Dusky blue nail beds are associated with cyanosis. A yellow tinge to the forehead is associated with carotenemia.

An unresponsive client with a light complexion has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client's face is a cherry-red color. What should the nurse suspect?

Carbon monoxide poisoning Explanation: Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry-red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark-skinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin.

A nurse on assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement?

Check the client's oral temperature. Explanation: Erythema is pink or a red skin shade that is caused by dilation of the capillaries. In clients who are more light-skinned, it is easily observable. Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. This color may be seen when there is inflammation or fever, so checking the client's oral temperature should be the nurse's priority. Once the client's temperature is established, interventions such as lowering the thermostat in the room, providing additional blankets, and/or conducting a more detailed assessment can be determined. A change in the client's skin color should always be investigated.

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections?

Diabetes Explanation: Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

A nurse is reviewing gerontologic considerations relating to the care of clients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?

Diminished protection of tissues and organs Explanation: Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?

Ecchymoses Explanation: Telangiectasias consist of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticaria is wheals or hives.

The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based?

Eczema Explanation: There are some skin conditions that are genetically based. Eczema is one such condition that does not have a distinct inheritance pattern but does have a genetic predisposition for the condition. Rash is not considered a genetically based skin condition. Xanthelasmas or yellowish waxy deposits on the upper and lower eyelids and seborrheic keratoses or crusty brown patches are both considered benign skin changes in the skin of an older adult.

The nurse is caring for a 72-year-old female client with a stage 2 pressure injury on the left heel.

Elevate head of bed to 45 degrees. Place a heat lamp over wound. Assess and document wound. Place mattress overlay on bed. Limit protein in the diet. Turn and reposition every 2 hours. Explanation: Nursing measures should be implemented to relieve pressure on bony prominences to prevent new pressure injuries and to allow the present wound to heal. The client should be turned and repositioned every 2 hours to relieve and redistribute pressure on the client's skin. The wound should be assessed and documented in the medical record so that the nurse can determine the therapeutic effectiveness of nursing interventions. The head of the bed should be elevated to no more than 30 degrees to prevent shearing forces as the patient slides down the bed. Proteins can drain from a wound predisposing the patient to hypoproteinemia. Therefore, proteins should be encouraged rather than limited in the diet. The wound should be kept moist to encourage the migration of epidermal cells over the wound surface. Therefore, a heat lamp should not be used since it would dry out the wound and impair healing.

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?

Elevated and palpable Explanation: The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, nonpalpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster Explanation: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined.

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.

Fingernails Hair Skin Explanation: Nails are layers of hard keratin that have a protective function. The epidermis contains an outer layer of dead skin that forms a tough protective protein called keratin. Hundreds of strands of keratin link together with amino acids to form hair. Endocrine glands and subcutaneous tissue are not made of keratin.

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding?

Iron deficiency anemia Explanation: The concave shape of the nails, referred to as spooning, is a sign of iron deficiency anemia. Clubbing of the nails, at greater than a 160-degree angle, suggests long-standing cardiopulmonary disease. Nails thicken when there is a fungal infection and poor circulation.

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding?

It is a cherry angioma that is a normal age-related skin alteration. Explanation: A cherry angioma is a papular and round area that is red, found on extremities, and may blanch with pressure. This lesion is considered a normal age-related skin change. A spider angioma is red with a central body and radiating branches that is associated with liver disease. A telangiectasia has a shape like a spider that is caused by the dilation of venous vessels and varicose veins. Ecchymoses are round or irregular macular lesions that vary in color and are associated with trauma or bleeding.

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification Explanation: Lichenification is a thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue Explanation: The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?

Macule Explanation: A flat, nonpalpable, circumscribed lesion less than 1 cm is a macule. A patch is a macule larger than 1 cm, and possibly with an irregular border. A papule is an elevated palpable solid mass with a circumscribed border and less than 0.5 cm. A plaque is a papule greater than 0.5 cm.

A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative allergen?

Patch testing Explanation: Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely?

Patch testing Explanation: Patch testing would be most likely for a patient with a history of allergies to identify substances that may be involved with the patient's allergy. A skin biopsy is done to rule out a malignancy and establish an exact diagnosis. Tzanck smear is used to examine cells from blistering skin conditions. Wood's light examination is used to differentiate epidermal from dermal lesions and hyperpigmented and hypopigmented lesions.

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted?

Purple-gray cast Explanation: Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. Inflammation in light-skinned people is noted by erythema, or redness of the skin.

A client with vitamin D deficiency is receiving education from the nurse. What would be an appropriate recommendation by the nurse?

Spend time outdoors at least twice per week. Explanation: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). It is estimated that most people need 5 to 30 minutes of sun exposure twice a week in order for this synthesis to occur. Increasing intake of water is not related to resolving vitamin D deficiency. Vitamin D is unrelated to meat and vegetable intake.

A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component?

Subcutaneous tissue Explanation: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?

Tzanck smear Explanation: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. This is not accomplished by biopsy, patch test, or Wood light.

Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?

Ulcer Explanation: A pressure ulcer that is stage 2 or greater is one that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle Explanation: A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?

Yellowish waxy deposits on the eyelids Explanation: Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia. Solar lentigo refers to liver spots. Melasma refers to dark discoloration of the skin. Cherry angioma is the term used to describe a bright red mole.

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia. Explanation: In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky-white spots. Local arterial insufficiency is characterized by marked localized pallor.

The nurse is assessing an African American client and notes a streak of pigmentation in the client's fingernails. The nurse determines that this finding indicates

normal variation. Explanation: Variation in skin pigment in clients with dark skin, such as pigmented streaks in the nails, pigmented spots on the sclera of the eye, and a pigmented crease across the bridge of the nose, are considered normal color variations.

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as

petechiae. Explanation: Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.

Which structure or process does not keep the body warm?

respiration Explanation: Heat dissipates through the skin and through respiration. Heat is generated and conserved through cellular metabolism, body hair, and shivering. Erector muscles elevate hair shafts, preserving heat.

Which findings from a nail assessment are considered abnormal? Select all that apply

spooning clubbing Explanation: Spooning is the descriptor for concave-shaped nails and is a sign of iron-deficiency anemia. Clubbing of the nails, evidenced by an angle greater than 160 degrees suggests long-standing cardiopulmonary disease. Pink nail beds suggest adequate oxygenation. To assess tissue perfusion, the nurse compresses the nail beds, causing them to blanch, and then releases them. Color returns normally in 3 seconds or less. This assessment is called capillary refill time.

The nurse is preparing to assess a client's integumentary status. Which charactertistics of the skin will the nurse assess by using the technique of palpation? Select all that apply.

urgor Edema Elasticity Explanation: Inspection and palpation are the techniques used to examine the skin. Palpation is used to assess for skin turgor, edema, and elasticity. Inspection is used to assess for color and signs of infestation.

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as

vesicles. Explanation: The lesions form herpes zoster are vesicles, defined as circumscribed, elevated, palpable masses that contain serous fluid and are less than 0.5 cm in diameter. Wheals are elevated masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated fluid-filled or semisolid masses in the subcutaneous tissue or dermis.