Unit 15 Prep U Chs 51 & 52
A client with pale skin, white hair, and pink eyes comes to the clinic for a routine physical exam. Based on the client's appearance, the nurse knows this client has a genetic lack of which enzyme?
Tyrosinase
Fingernails and toenails, unlike hair, grow continuously. The nail plate itself is nearly transparent and acts as a window for viewing:
The amount of oxygen in the blood The nearly transparent nail plate provides a useful window for viewing the amount of oxygen in the blood, providing a view of the color of the blood in the dermal vessels.
Which client would the nurse be most concerned about?
The client with herpes zoster affecting the trigeminal nerve The nurse would be most concerned about the client with herpes zoster affecting the trigeminal nerve, as an episode affecting the face can affect hearing or vision. Blindness or deafness could result. Prodromal episodes are very common, as is postherpetic neuralgia.
In severe Stevens-Johnson syndrome and toxic epidermal necrolysis, hospitalization is required. When large areas of the skin are lost, what intravenous medication may speed up the healing process?
Immunoglobulin Intravenous immunoglobulin may hasten the healing response of the skin. Broad-spectrum antibiotics and corticosteroids may be given, but they do not hasten the healing response of the skin. Fluconazole is given for vaginal candidiasis.
Which statement concerning hair follicles is true?
Red hair has spherical melanosomes.
A public health nurse is teaching a group of individuals about sun protection. When teaching about sunscreen, the nurse should teach the individuals that:
using a product that contains a benzophenone is appropriate. Sunscreen agents no longer contain para-aminobenzoic acid (PABA), a chemical blocking agent that protects against UVB, because of its allergenic and staining properties. However, PABA derivatives are used widely, but protect only against UVB. Broad-spectrum suntan lotions protect against both UVA and UVB. These products contain a benzophenone, such as oxybenzone, dioxybenzone, or avobenzone. Children younger than 18 years of age should use broad-spectrum (blocks UVA and UVB) sunscreens that have a Sun Protection Factor (SPF) of at least 30. Sunscreens have proven benefits in the prevention of skin cancer.
A client with a parathyroid tumor has elevated calcium levels and low vitamin D levels. The provider suggests that the client get 15 to 20 minutes of unprotected sunlight per day, if possible. How will the provider explain why this intervention will help raise vitamin D levels for this client?
"A substance called 7-dehydrocholesterol is converted to an inactive form of vitamin D by UV rays from the sun." The skin functions as an endocrine organ, in which a substance called 7-dehydrocholesterol is converted to an inactive form of vitamin D by UV rays from the sun. It has nothing to do with vasodilation and exposing more blood vessels to the sun rays. It also does not affect the amount of calcium in one's vessels. The rate at which heat is dissipated from the body is determined by constriction or dilation of the arterioles that supply blood to the skin and through evaporation of moisture and sweat from the skin surface.
Lentigines are skin lesions common in older adults. A type of lentigo is tan to brown in color with benign spots. Lentigines are removed because they are considered precursors to skin cancer. How are lentigines removed?
Cryotherapy Lentigines can be removed surgically (cryotherapy, laser therapy, liquid nitrogen). Topical creams and lotions containing adapalene and tretinoin have been used.
What should a nurse tell a client who is concerned about melasma?
"Stay out of the sun." A client who has melasma should stay out of the sun, as the condition is exacerbated by sun exposure. The use of lotion, steroid cream, or itching should not affect the condition.
A client asks "Why do I have albinism?" What is the nurse's best answer?
"You inherited this disorder." Albinism is an inherited genetic disorder in which there is complete or partial congenital absence of pigment in the skin, hair, and eyes.
A nurse is caring for four clients. Which client is at highest risk for the development of a pressure injury?
72-year-old client who is undernourished and recently underwent thigh surgery Populations at risk for pressure injuries include clients with quadriplegia and older adults with restricted activity and hip fractures in a critical care setting. A postsurgical client who is undernourished is at risk for pressure injury development.
Most of the body's hair follicles are paired with which anatomical part?
A sebaceous gland Most hair follicles are associated with sebaceous glands, and these structures combine to form the pilosebaceous unit. Langerhans cells are not paired with hair follicles, and apocrine glands, not eccrine glands, are often associated with a hair follicle. Nerve endings are widely distributed throughout the skin, but these are not paired with hair follicles.
A client has been diagnosed with lentigo. Which is the most accurate description of lentigo?
A small lesion of melanocytes Lentigo maligna (i.e., Hutchinson freckle) is a small, slowly progressive neoplastic disorder of melanocytes. The lesion is a pigmented macule with a well-defined border and grows to 5 cm or sometimes larger.
Which skin disorder seen in older adults is considered a premalignant lesion?
Actinic keratosis Actinic keratoses are the most common premalignant skin lesions that develop on sun-exposed areas. Solar lentigines are tan to brown, benign spots on sun-exposed areas. They are commonly referred to as liver spots. Senile angiomas (cherry angiomas) are smooth, cherry-red or purple, dome-shaped papules, usually found on the trunk. Telangiectases are single-dilated blood vessels, capillaries, or terminal arteries that appear on areas exposed to sun or harsh weather, such as the cheeks and the nose.
Which disorder of the skin is most likely to respond to treatment with systemic antibiotics like tetracycline?
Acne vulgaris The etiology of acne vulgaris is bacterial, and some clients may require treatment with systemic antibiotics. Urticaria (hives) and atopic dermatitis result from allergic and hypersensitivity processes. Verrucae, or warts, are of viral origin and thus unresponsive to antibiotic therapy.
Which client would be predisposed to developing a yeast-like Candida albicans fungal infection?
An immunosuppressed client with cancer who has developed maculopapular satellite lesion In addition to microscopic analysis of skin scrapings for tinea fungal spores, a candida infection often can be differentiated from a tinea infection by the presence of maculopapular satellite lesions found outside the clearly demarcated borders. Some persons are predisposed to candida infections by conditions such as diabetes mellitus, antibiotic therapy, pregnancy, oral contraceptive use, poor nutrition, and immunosuppressive diseases. The most common types of tinea lesions are oval or circular patches with raised red borders consisting of vesicles, papules, or pustules on exposed skin surfaces.
Which characteristic differentiates apocrine sweat glands from eccrine sweat glands?
Apocrine secretions contain oils. The major difference between apocrine glands and the eccrine glands is that apocrine glands secrete an oily substance. Apocrine glands are less widely distributed than eccrine glands, and they do not contribute as significantly to thermoregulation. Neither is a major contributor to skin pH.
The basement membrane, the interface between the epidermis and dermis, is involved in formation of which skin disorders?
Blister formation The basement membrane (formerly called basal lamina) is involved in skin disorders that cause bullae or blister formation. The stratum spinosum is two to four layers thick, consisting of cells commonly referred to as prickle cells because they develop a spiny appearance as their cell borders interact. The melanocytes are pigment-synthesizing cells that are located at or in the basal layer, functioning to produce pigment granules called melanin. The papillary dermis lies adjacent to the epidermis and is densely covered with conical projections called dermal papillae.
A nurse is assessing a client with a 2-cm second-degree burn on the arm. This burn is characterized by the presence of:
Bullae A bulla is a circumscribed, elevated, palpable mass containing serous fluid that is greater than 0.5 cm.
A client is admitted to the hospital with thermal injuries as a result of a fire. What type of damage of the skin can occur as a result of the thermal injuries? Select all that apply.
Cause damage to the skin and subcutaneous tissue Destroy the barrier function of the skin Thermal injury can damage skin and subcutaneous tissue and destroy the barrier function of the skin in terms of preventing the loss of body fluids and protecting against the entry of infectious organisms. The ultraviolet rays of sunlight have the potential for directly damaging skin cells, accelerating the effect of aging on the skin, and predisposing to the development of skin cancer.
A client presents to the urgent care and tells the health care provider he came home from vacation 4 days ago and does not feel well. Upon assessment, the provider notes the client's right upper thigh area is red, warm, and painful, and the lymph nodes are palpable. The client states he had been swimming in a lake all week. The health care provider recognizes these manifestations as:
Cellulitis Cellulitis is a deeper infection affecting the dermis and subcutaneous tissues. It is usually caused by group A beta-hemolytic streptococci or Streptococcus aureus but can be caused by bacteria specific to certain activities, such as fish handling, swimming in fresh or salt water, or from animal bites or scratches. Legs are the most common sites. It is frequently accompanied by fever, erythema, heat, edema, and pain and often involves the lymph system. The other options would not have these manifestations.
An older adult client asks the nurse why her skin is so dry. Which response is best for the nurse to give to this client? Select all that apply.
Changes occur in the sebaceous gland. Flattening of the dermal rete ridges occurs. A decrease in skin capillaries occurs. The effects of aging on skin dryness include a change in the composition of sebaceous gland secretions and a decrease in the secretion of moisture from the sweat glands. Aging is also accompanied by a decrease in skin capillaries as well as a flattening of the dermal rete ridges, resulting in less surface area for exchange of fluids between the dermis, epidermis, and skin surface.
The basement membrane separates the epithelium from the underlying connective tissue. Which function does it play regarding skin disorders like blister formation?
Complement deposition The basement membrane is also a major site of immunoglobulin and complement deposition in skin disease.
A client has a vascular lake on the back of the right hand. What are common methods for removal of this type of vascular lesion? Select all that apply.
Electrosurgery Laser therapy Surgical excision Venous lakes can be removed by electrosurgery, laser therapy, or surgical excision if a person desires.
A fair-skinned, red-haired client comes to the clinic for a routine physical and receives education about regularly applying sunscreen to prevent skin cancer. Which risk factors makes fair-haired clients more susceptible to skin cancer?
Enhanced photoreactivity of pheomelanin Pheomelanin, the yellow-to-red pigment, is found in all humans. It is particularly concentrated in the lips, nipples, glans penis, and vagina. Besides the skin, it is found in hair, particularly red hair. It has been suggested that the reason fair-haired people are more susceptible to skin cancers may be due to the enhanced photoreactivity of pheomelanin, as compared with eumelanin.
Allergic and hypersensitivity dermatoses are usually characterized by which descriptor?
Epidermal edema Allergic and hypersensitivity dermatoses involve the inflammatory response and are usually characterized by epidermal edema with separation of epidermal cells. Rosacea is characterized by repeated episodes of facial blushing that eventually becomes a permanent dark red erythema on the nose. The lesions of erythema multiforme are round, erythematous papules that enlarge and coalesce, changing to concentric zones of color appearing as "target" or "iris" lesions.
Following exposure to poison oak while camping, a 20-year-old male is experiencing pruritis as a consequence of his immune response to irritants in the plant. What physiologic process best accounts for his complaint?
Free nerve endings are initiating an itch-specific signal to the somatosensory cortex. It is generally agreed that itch is a sensation that originates in free nerve endings in the skin, is carried by small myelinated type C nerve fibers to the dorsal horn of the spinal cord, and is then transmitted to the somatosensory cortex via the spinothalamic tract. Itching is no longer considered to be a low-level pain response. Ruffini corpuscles and Langerhans cells are not noted to play a role in pruritus.
Which process accounts for the damaging effects of the sun's radiation?
Generation of reactive oxygen species and damage to melanin Ultraviolet (UV) B radiation is primarily responsible for sunburns, and it acts mainly on the cells in the basal layer of the epidermis, causing the generation of reactive oxygen species and damage to melanin. It also provokes free radical production and induces a significant reduction in skin antioxidants, impairing the ability of the skin to protect itself against the free radicals that are generated. UV radiation does not provoke an autoimmune response or hyperkeratinization, although there is an inflammatory response. Increased melanin production is a protective mechanism and does not participate in the deleterious effects of UV radiation.
Which stratum layer of the epidermis has cells working to lose cytoplasm and DNA while synthesizing keratin?
Granulosum The stratum granulosum contain the most differentiated cells in the living skin, with some cells losing cytoplasm and DNA, while others in this layer synthesize keratin. The remaining options do not perform the described functions.
A client with third-degree burns over 40% of his body is best cared for in which type of health care environment?
Hospital admission and referral to burn center Minor burns are managed on an outpatient basis. Moderate burns involve a hospital admission. Major burns in involve hospital admission with a referral to a burn center if available.
An individual has developed blisters on the palms of her hands after gardening for several hours. What physiologic process has contributed to the client's blisters?
Intercellular junctions have separated, allowing the accumulation of fluid. In the development of blisters, there is degeneration of the epidermal cells and a disruption of the intercellular junctions, causing the layers of the skin to separate. As a result, fluid accumulates and a noticeable bleb forms on the skin surface. This fluid is not sweat, however. Rupture of epidermal cells does not cause blisters.
Scabies infections are caused by mites that burrow under the skin. They are usually easily treated by bathing with a mite-killing agent and leaving it on for 12 hours. When scabies are resistant to the mite-killing agent, what oral drug is prescribed?
Ivermectin Oral ivermectin, a broad-spectrum antiparasitic agent, has been used for treatment-resistant scabies. The other drugs are not used for treatment-resistant scabies.
Which intervention will the nurse recommend for the client who has tinea versicolor?
Ketoconazole cream or shampoo The client with tinea versicolor is usually treated with ketoconazole cream on the lesions, or even shampoos with ketoconazole left on the areas when the client showers.
A student with a rash goes to the school nurse for evaluation. The nurse suspects the student has contact dermatitis. The primary cell responsible for this delayed-type hypersensitivity reaction is:
Langerhans cells As antigen-presenting cells, the Langerhans cells are involved in delayed-type hypersensitivity reactions such as contact dermatitis and other cell-mediated immune responses in the skin; their dendritic processes extend through keratinocytes, forming a network to bind and process antigen. Merkel cells provide sensory information to the skin. In the dermis, the reticular dermis is a complex meshwork of three-dimensional collagen bundles that contain dermal dendrocytes, which have phagocytic properties.
A client has been using a topical antibiotic ointment on a urticaria skin disorder. Which best describes the drug-induced skin eruption caused by topical drugs?
Localized contact dermatitis Most drugs can cause a localized or generalized skin eruption. Topical drugs are usually responsible for localized contact dermatitis types of rashes, whereas systemic drugs cause generalized skin lesions.
A nurse educator is instructing students on the importance of a skin assessment to help identify underlying systemic disease. Which assessments are correctly correlated to the identified disease? Select all that apply.
Malar rash associated with systemic lupus erythematosus Bronze skin associated with Addison disease Jaundice associated with liver disease The skin may demonstrate outwardly what occurs inside the body. A number of systemic diseases are manifested by skin disorders (e.g., malar rash associated with systemic lupus erythematous, bronze skin with Addison disease, and jaundice with liver disease). Cyanosis is associated with hypoxia, not diabetes.
A client has sought care for a serious sunburn that resulted from falling asleep at the beach. What physiologic process was involved in the client's overexposure to ultraviolet radiation?
Melanocytes were unable to sufficiently protect that client Melanocytes produce a pigment called melanin that is responsible for skin color, tanning, and protecting against ultraviolet radiation. Keratinocytes in the epidermis provide external strength and protection. Merkel cells provide sensory information. Langerhans cells link the epidermis to the immune system.
Following a severe sunburn that resulted in second-degree burns with multiple blisters, the skin team nurse notices that after several weeks of treatment, the skin appears to be regenerating. The nurse contributes this to which structure of the skin?
Merkel cells Merkel cells are epidermal cells that function in cutaneous sensation. Merkel cells display distinctive, dense granules in their organelles and cytoplasm, suggesting that they possess neurosecretory function. These functions may include metabolic support of their associated neurons, neuron development, and regeneration after injury. The basement membrane zone is an interface between the dermis and epidermis. The keratinocytes are the predominant cell type of the epidermis. They produce a fibrous protein called keratin, which is essential to the protective function of skin and may be involved in the immune system. Langerhans cells are dendritic cells that reside principally in the stratum spinosum of the epidermis and play a major role in the functioning of the skin's immune system.
The nurse caring for a client with extreme xerosis applies which type of agent to minimize the loss of water from the skin?
Occlusives Occlusives are thick creams that contain moisture-proof material to prevent water loss from the skin. They would be the best treatment option since the other options are not directed toward this treatment goal.
The clinic health care worker notices that a client has a fungal infection on her nails that looks like the fungus is digesting the nail keratin. The nail appears opaque and white in color. The client states she has had this for years. The health care worker suspects the client has:
Onychomycosis Onychomycosis often begins at the tip of the nail, where the fungus digests the nail keratin. Initially, the nail appears opaque, white, or silvery. The nail then turns yellow or brown and remains unchanged for years. Gradually, the nail thickens and cracks as the infection spreads. Candidiasis (moniliasis) is a fungal infection caused by C. albicans. This yeast-like fungus is a normal inhabitant of the gastrointestinal tract, mouth, and vagina. Cellulitis is a deeper infection affecting the dermis and subcutaneous tissues. The lesion consists of an expanding red, swollen, tender plaque with an indefinite border, covering a variety of widths. Cellulitis is frequently accompanied by fever, erythema, heat, edema, and pain. Tinea corporis (ringworm of the body) are oval or circular patches on exposed skin surfaces and the trunk, back, or buttocks.
A client presents with a rash on the face and arms. It is primarily flat with a few areas that are raised. The nurse would document the flat lesions that are greater than 1 cm in diameter as being which type of lesion?
Patches Both macules and patches are flat, nonpalpable lesions that present as brown, white, tan, purple, or red changes in the color of the skin. A macule is less then 1 cm in diameter and a patch is greater than 1 cm in diameter. A papule is a solid mass that is elevated and palpable with a circumscribed border that is less than 1 cm in diameter. A nodule is an elevated, palpable solid mass that extends deeper into the dermis than a papule and is 0.5 to 2 cm in diameter. A vesicle is an elevated, palpable mass containing serous fluid that is less than 1 cm in diameter.
A nurse is teaching a client about psoriasis. The nurse knows that teaching is effective when the client correctly identifies which lesions as being associated with psoriasis? Select all that apply.
Plaques Scales A plaque is an elevated, palpable, solid mass with a circumscribed border. Scales are flakes secondary to desquamated, dead epithelium that may adhere to skin surface. Their color varies (silvery, white) and their texture varies (thick, fine). Both types of skin lesions can be found with psoriasis.
Our bodies have, as endemic organisms, both yeast (Candida albicans) and molds. When a fungus invades the skin of our body, what is used as a confirmatory diagnostic tool?
Potassium hydroxide preparations Treatment of fungal infections usually follows diagnosis confirmed by potassium hydroxide preparation or culture.
A client is being evaluated for malignant melanoma. What is a risk factor associated with the development of malignant melanoma?
Presence of actinic keratoses Other risk factors include a family history of malignant melanoma, presence of marked freckling on the upper back, history of three or more blistering sunburns before 20 years of age, and presence of actinic keratoses.
The first-line treatment for dry skin is moisturizing agents. How do these agents work?
Repairing the skin barrier Moisturizing agents are the cornerstone of treatment for dry skin. These agents exert their effects by repairing the skin barrier, increasing the water content of the skin, reducing transepidermal water loss, and restoring the lipid barrier's ability to attract, hold, and redistribute water.
Which cells are characterized by a complex meshwork of dense collagen bundles interconnected with large elastic fibers and a viscid gel that is rich in mucopolysaccharides?
Reticular cells The reticular dermis (pars reticularis) is the thicker area of the dermis and forms the bulk of the dermal layer. The other three answers are part of the reticular dermis, but it is not characterized by them.
Select the layer of dermis characterized by a complex meshwork of three-dimensional collagen bundles interconnected with large elastic fibers.
Reticular dermis
A nurse is assessing the skin of an aging adult. Which findings does the nurse note as being a normal part of the aging process? Select all that apply.
Scaly Dry skin As the skin ages, it becomes wrinkled, thin, dry, rough, scaly, and itchy. Although unevenly pigmented skin is a normal finding in the aging adult, unevenly pigmented moles can be a sign of skin cancer and is therefore not a normal part of the aging process. Lentigo maligna is a slowly progressive preneoplastic disorder of melanocytes. It occurs on sun-exposed areas, particularly the face. The lesion is a pigmented macule with well-defined border and grows to 5 cm.
A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:
Second-degree partial thickness Second-degree partial-thickness burns involve the epidermis and parts of the dermis. First-degree partial-thickness burns involve only the outer layers of the epidermis. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve bone and muscle. Second-degree full-thickness burns involve the entire epidermis and dermis.
The basement membrane between the epidermis and dermis provides for adhesion and serves which function regarding molecule transportation?
Selective filter The basal lamina (basement membrane) is a layer of intercellular and extracellular matrices that provides for adhesion and serves as a selective filter for molecules moving between the two layers. The papillary dermis and reticular dermis are composed of cells, fibers, ground substances, nerves, and blood vessels. The dermis supports the epidermis, serves as its primary source of nutrition, and contains encapsulated pressure-sensitive receptors that detect pressure and touch.
The nurse planning a sun safety community education class should include the information that the increased melanin produced by dark-colored skin decreases the risk for:
Skin cancer The increased melanin produced by dark skin decreases the risk for skin cancer, premature wrinkling, and aging of the skin that occurs with sun exposure. Skin color is not a factor when considering the other options.
A nurse educator is preparing an education module on the dermis layer of the skin for the nursing staff. Which statements should be included in the module? Select all that apply.
The dermis is the connective tissue layer. The pink color of light skin results primarily from blood in the vessels of the dermis. The glandular structures are embedded in this layer. The dermis is the connective tissue layer that separates the epidermis from the subcutaneous fat layer. It consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatics.
Which statements are true regarding the skin disorder referred to as a corn? Select all that apply.
They are well circumscribed. They can be either hard or soft. Their location determines whether they are painful. Their medical name is helomas. Corns (helomas) are small, well-circumscribed, conical, keratinous thickenings of the skin. The corn may be either hard (heloma durum) with a central hard, horny core, or soft (heloma molle), as commonly seen between the toes. Corns on the feet often are painful, whereas corns on the hands may be asymptomatic. A callus is a hyperkeratotic plaque of skin due to chronic pressure or friction.
An individual has suffered an electrical burn. Which term best describes this burn and should be included in the electronic medical record?
Third degree A sunburn is an example a first degree burn. Scalding water is an example of superficial partial-thickness second degree burn. Fire burn is an example of deep partial-thickness second degree burn. Electrical burn is an example of a full-thickness third degree burn.
The pars reticularis is characterized by what?
Three-dimensional collagen bundles The reticular dermis (pars reticularis) is the thicker area of the dermis and forms the bulk of the dermal layer. The other three answers are part of the reticular dermis, but it is not characterized by them.
A client has an appointment concerning the possible diagnosis of malignant melanoma. Which statement is correct concerning malignant melanoma?
Tumor thickness is a very important factor. Malignant melanomas are determined by tumor thickness. A complete excisional biopsy of a lesion is completed for malignant melanoma. Melanomas frequently develop metastasis.
An older adult client has noticeable dry skin that is rough and scaly. The client is frequently scratching, resulting in cracking and other skin problems. Which intervention(s) would the nurse consider important to discuss with this client? Select all that apply.
Use occlusive, petroleum-based creams every morning and night Use room humidifiers, especially in bed room Apply emollients to the skin surface, applying frequently Emollients are fatty acid-containing lotions that replenish the oils on the skin surface, but usually do not leave a residue on the skin. They have short duration of action and need to be applied frequently. Using a room humidifier and keeping room temperatures as low as possible to prevent water loss from the skin may be helpful. Glycerin soaps, although popular and visually appealing, are drying and can exacerbate the symptoms. Occlusives are thick, petroleum-based creams that can form a barrier. They prevent water loss from the skin. They are most effective for relieving skin dryness, but because of their greasiness and lack of cosmetic appeal, some people do not wish to use them.
A nurse is preparing for a certification course in wound care and needs to be able to identify various lesions that may be identified when assessing the skin. Which definitions are correctly identified with their skin lesion? Select all that apply.
Vesicle: A circumscribed, elevated, palpable mass containing serous fluid, <0.5 cm Nodule: Solid, elevated, hard or soft, larger than 0.5 cm circumscribed Pinpoint spots of petechiae may be blanched (white), erythematous (reddened), hemorrhagic or purpuric (containing blood), or pigmented (colored). A papule is an elevated, palpable, solid mass with a circumscribed border. A bulla is a circumscribed, elevated, palpable mass containing serous fluid. Vesicle: <0.5 cm; Bulla: >0.5 cm. Nodule is an elevated, palpable, solid mass that extends deeper into the dermis than a papule 0.5-2 cm circumscribed.
Which skin disorder is likely to result from the localized lack of melanin production by melanocytes?
Vitiligo In cases of vitiligo, depigmented areas may contain no melanocytes, greatly altered or decreased amounts of melanocytes, or, in some cases, melanocytes that no longer produce melanin. Melasma results from increased pigmentation. Neither bullae nor rashes are consequences of alteration in melanocyte function.
A skin care consultant informs the client that he needs to bathe and use a soft cloth to remove dead cells on the skin surface. The rationale for this action is based on the fact that
a basal cell is mitotically active and pushes older dead cells to the skin's surface. The basal cells are the only epidermal cells that are mitotically active. All cells of the epidermis arise from this layer. As new cells form in the basal layer, the older cells change shape and are pushed upward toward the skin surface. The second layer, the stratum spinosum, is two to four layers thick. The cells of this layer are commonly referred to as prickle cells because they develop a spiny appearance as their cell borders interact. The keratinocytes are the predominant cell type of the epidermis. They produce a fibrous protein called keratin, which is essential to the protective function of skin and may be involved in the immune system and wound healing.
A client is diagnosed as having a bullous pemphigoid, a condition that leads to chronic blister formation. The nurse teaches the client that the blisters are occurring in which layer of the skin?
basement membrane zone Bullous pemphigoid is an autoimmune blistering disease caused by autoantibodies to constituents of the dermal-epidermal junction. The basement membrane zone is a thin adhesive layer that cements the epidermis to the dermis at this junction, and is the layer involved in blister formation.
Which describes a stage III pressure injury?
full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia Stage I pressure injuries are characterized by a defined area of persistent redness in lightly pigmented skin or an area of persistent redness with blue or purple hues in darker skin. Stage II pressure injuries represent a partial-thickness loss of skin involving the epidermis or dermis, or both. Stage III pressure injuries represent a full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The pressure injury manifests as a deep crater with or without undermining of adjacent tissue. Stage IV injuries involve full-thickness skin loss and necrosis with extensive destruction or damage to the underlying subcutaneous tissues that may extend to involve muscle, bone, and supporting structures.
The nurse is assessing a client with multiple nevi. Which assessment by the nurse is the priority?
interviewing the client about any recent changes in the nevi Nevi, or moles, are common and considered benign. Because of the possibility of malignant transformation, any mole that undergoes a change is the priority to identify and assess. Therefore, the priority assessment is interviewing the client about recent changes. This is the most efficient and focused assessment. The nurse would ask the client about changes in size, thickness, or color, itching, and bleeding. The nurse can also assess the nevi in the other ways listed, but these are not the most important assessments.
The nurse is assessing a client with darker skin. The nurse is aware that: Select all that apply.
it will be difficult to assess skin pallor (pale appearance) erythema (reddening of skin) will be difficult to observe. verbal histories are important in skin assessment. Normal variations in skin structure and skin tones often make evaluation of dark skin difficult. The darker pigmentation can make skin pallor, cyanosis, and erythema more difficult to observe. Therefore, verbal histories must be relied on to assess skin changes.
A client has a stage III pressure injury in the sacral area. What factor(s) can contribute to the development of pressure injuries? Select all that apply.
pressure friction shearing force Four factors contribute to the development of pressure injuries: (1) pressure, (2) shearing forces, (3) friction, and (4) moisture.
The nurse is assessing a client's sacral pressure injury. There is breakdown of the dermal layer, but no exposure of the subcutaneous tissue. The nurse will document the injury as which stage?
stage II Stage I pressure injuries are characterized by a defined area of persistent redness in lightly pigmented skin or an area of persistent redness with blue or purple hues in darker skin. Stage II pressure injuries represent a partial-thickness loss of skin involving the epidermis or dermis, or both, but no exposure of the subcutaneous tissue. Stage III pressure injuries represent a full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The pressure injury manifests as a deep crater with or without undermining of adjacent tissue. Stage IV pressure injuries involve full-thickness skin loss and necrosis with extensive destruction or damage to the underlying subcutaneous tissues that may extend to involve muscle, bone, and supporting structures.
