Skin

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? A. Smooth, defined border B. Uniform color C. Size of a pencil eraser D. Symmetrical appearance

C. Size of a pencil eraser. Lesions greater than 6 mm or the size of a pencil eraser in diameter should be recognized as a possible malignant skin lesion and should be reported to provider.

A nurse is palpating a client's extremities and notes lower left leg is cooler to touch than client's right leg or arms. How should the nurse interpret this finding? A. Client may have a blood clot B. Client may have an infection C. Client is experiencing complications of kidney failure D. Client's blood oxygen levels are lower than expected

A. Client may have a blood clot Unilateral coolness is associated with decreased blood flow to the extremity. This can occur when the client is experiencing a blood clot that is blocking the flow of blood. Additional causes of unilateral coolness of an extremity include chronic disease of the blood vessels or a physical obstruction of blood flow, such as from a cast that is too tight.

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? A. Limit elevation of head of bed to 30 degrees or less B. Apply baby powder and massage area every 2 hrs C. Reposition client every 4 hrs D. Ensure client uses donut-shaped cushion while sitting in chair

A. Limit elevation of head of bed to 30 degrees or less Raising the head of the bed more than 30º increases the risk for skin damage due to shearing forces. Shearing occurs when the client slides downward in the bed. The outer skin layer sticks to the bed linens while the deeper skin layers move downward. This results in twisting of blood vessels and can lead to skin damage.

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting characteristics of the wound? Select all that apply. A. Location of pressure injury B. Size of injury in cm C. Depth of injury in cm D. Color and odor of drainage from wound E. Integrity of skin surrounding wound

A. Location of pressure injury B. Size of injury in cm E. Integrity of skin surrounding wound. The nurse should document the location of pressure injury related to adjacent bony prominences, the length and width of pressure injury in cm, and the condition of the wound edges and area of skin surrounding pressure injury. Nurse should also note any changes in temperature, sensation, or firmness in area.

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use? A. Penlight B. Otoscope with pneumatic bulb attachment C. Wide-tipped speculum D. Tongue blade

A. Penlight The nurse should plan to perform a skin assessment in an area with strong lighting for general visualization. A penlight is used to illuminate suspicious areas of the skin.

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment? A. "When I was a child, I developed a rash after taking amoxicillin." B. "I noticed that my fingernails have changed recently." C. "I used to take baths, but I recently switched to showering." D. "In my family, one cousin has basal cell carcinoma."

B. "I noticed that my fingernails have changed recently." The nurse should follow up with additional questions for the client to obtain specific information about the nail changes the client has observed.

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? A. Lateral to umbilicus B. Inferior to collar bone C. Dorsal side of hand D. Anterior aspect of neck

B. Inferior to collar bone. Assessing skin turgor is performed by pinching large fold of skin just below clavicle. Other reliable sites include over the sternum and back of forearm. In older adults, loss of elasticity might slow the recoil time of skin.

A nurse is assessing a client's skin color. Which of the following should the nurse report to the provider? Select all that apply. A. Patches of increased pigmentation on client's cheeks B. Pinpoint areas of purplish-red coloration across abdomen C. Pale-colored nailbeds D. Darkly pigmented area across client's sacral area E. Light-colored jagged lines

B. Pinpoint areas of purplish-red coloration across abdomen C. Pale-colored nailbeds Areas of purplish-red discoloration that are smaller than 3 mm in diameter are termed petechia. This is an unexpected finding. Petechia can be an indication of a bleeding disorder and should be reported to the provider. Pale nailbeds is an unexpected finding. They can be an indication of low oxygen levels and should be reported to the provider.

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection? A. Wheals B. Vesicles C. Papules D. Bulla

B. Vesicles. Vesicles are small, serous, fluid-filled skin lesions. The nurse should identify they are associated with both chickenpox and shingles infections and should be reported to provider.

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider? A. Skin tags on neck B. Yellow discoloration of palms C. Brown birthmark on thigh D. Absent tenting of skin

B. Yellow discoloration of palms Yellow discoloration of the skin, or jaundice, should be reported to the provider. It is caused by an elevated level of bilirubin, which is a by-product of the breakdown of red blood cells. Jaundice can occur in clients who have disorders of the blood or liver. Jaundice is visible throughout the body of clients who have light skin tones and is visible on the palms and soles of clients who have darker skin tones. The color change can be seen on all clients in the sclera and on the hard palate.

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicates an understanding of the teaching? A. "Exposing these areas to a tanning bed twice a month will decrease outbreaks." B. "Opening acne lesions will make them drain and go away faster." C. "I should wash areas frequently with warm water and soap." D. "Keeping skin moist with oil-based creams will prevent acne outbreaks."

C. "I should wash areas frequently with warm water and soap." Frequent washing of affected areas with warm water and soap will remove oil and dirt from skin. This will reduce risk of secondary infection occurring with lesions.

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? A. Increase frequency of bathing B. Use dehumidifier to reduce air moisture C. Apply alcohol-free lotion D. Cover dry areas with thin coating of powder

C. Apply an alcohol-free lotion. The nurse should recommend an alcohol-free lotion that creates film on skin to decrease moisture evaporation and dryness. Lanolin, cocoa butter, and petroleum-based lotions are products that retain skin moisture.

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should be reported to the provider? A. Yellowed nail color B. White horizontal lines C. Spongy nail base D. Capillary refill 2 seconds

C. Spongy nail base. Base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider.

A nurse is teaching a young adult about the risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching? A. "The fact that I have five moles increases my risk for developing melanoma." B. "My cousin had squamous cell carcinoma, which increases my risk for melanoma." C. "Having a light complexion decreases my risk for developing melanoma." D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult."

D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult." Excessive sun exposure and severe or blistering sunburns in childhood increase the risk for developing melanoma as an adult.

A nurse is assessing a client's skin color. Which of the following areas should the nurse check to determine the presence of pallor? A. Anterior chest B. Palms of hands C. Auricle of ears D. Mucous membranes

D. Mucous membranes. Pallor is a pale or lighter skin color than usual that can be caused by anemia or a circulatory problem. It is best observed by inspecting the color the mucous membranes, and nail beds.

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider? A. Thin skin B. Brown macules on the back of hands C. Silver-white depressed scars on abdomen D. Velvety skin

D. Velvety skin Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders. This is an unexpected finding that should be reported to the provider.