CH 11: Skin, Hair and Nails

bulla

-clear fluid filled greater than 1 cm

vesicle

-clear fluid filled less than 1cm -chicken pox

cyst

-filled with semi-solid material that vary in size

patch

-flat and greater than 1cm -psoriasis, ringworm

pustule

-purulent fluid filled lesion of any size

papule

-raised and less than 1cm

wheel

-raised flesh color papule or plaques that vary in size and shape -hives

plaque

-raised lesion greater than 1cm

nodule

-solid papule less than 1cm

A decrease in oxyhemoglobin will result in documentation of pallor. True False

True

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin a) A. b) B12. c) C. d) D.

d) D.

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? a) Anterior chest b) Upper abdomen c) On the neck d) Under the breast

d) Under the breast

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? a) "Are you allergic to foods, medications, or other substances?" b) "Does anyone else in your family have a rash like this?" c) "How painful is your rash?" d) "What have you been doing to control the itching?"

a) "Are you allergic to foods, medications, or other substances?"

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? a) "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." b) "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." c) "SPF 15 is the number of minutes that a person can safely stay in the sun after treating the skin with the product." d) "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn."

a) "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? a) Inspect the area b) Ask further questions c) Document the statement d) Move on to next body system

a) Inspect the area

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? a) The client has chronic hypoxia b) The client has melanoma c) The client has COPD d) The client has asthma

a) The client has chronic hypoxia

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown? a) high b) mild c) moderate d) negligible

a) high

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? a) Stage I b) Stage II c) Stage III d) Stage IV

b) Stage II

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? a) The client is elderly. b) The client may have been abused. c) The client may have peripheral vascular disease. d) The client may have a cognitive deficit.

b) The client may have been abused.

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? a) Insect bites b) Urticaria or hives c) Psoriasis d) Purpura

b) Urticaria or hives

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 a) stage I. b) stage II. c) stage III. d) stage IV.

b) stage II.

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? a) Stratum corneum b) Stratum lucidum c) Dermis d) Epidermis

c) Dermis

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? a) Moist and smooth b) Moist and rough c) Dry and rough d) Dry and smooth

c) Dry and rough

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? a) When palpating the texture of the client's skin b) When palpating the client's hair c) When palpating lesions on the client's skin d) When palpating the client's nail beds for texture and capillary refill

c) When palpating lesions on the client's skin

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the a) entire skin surface. b) soles of the feet. c) areola of the breast. d) adipose tissue.

c) areola of the breast.

Hair follicles, sebaceous glands, and sweat glands originate from the a) epidermis. b) eccrine glands. c) keratinized tissue. d) dermis.

d) dermis.

To assess an adult client's skin turgor, the nurse should a) press down on the skin of the feet. b) use the dorsal surfaces of the hands on the client's arms. c) use the finger pads to palpate the skin at the sternum. d) use two fingers to pinch the skin under the clavicle.

d) use two fingers to pinch the skin under the clavicle.

macule

-flat and less than 1cm -freckle

Short, pale, and fine hair that is present over much of the body is termed a) vellus. b) dermal. c) lanugo. d) terminal.

a) vellus.

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? a) Stage I b) Stage II c) Stage III d) Stage IV

b) Stage II

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? a) Vitiligo, hirsutism, vitamin deficiency b) Eczema, melanoma, herpes zoster c) Psoriasis, fungal infections, trauma d) Alopecia, dermatitis, chemotherapy

c) Psoriasis, fungal infections, trauma

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? a) Alcoholism b) Parkinson's disease c) Marfan syndrome d) Cushing syndrome

a) Alcoholism

The apocrine glands are stimulated by what? a) Emotional stress b) Temperature c) Physical stress d) Overhydration

a) Emotional stress

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? a) Hypoxia b) Infection c) A normal finding d) Vitamin C deficiency

a) Hypoxia

Which of the following assessment findings most likely constitutes a secondary skin lesion? a) Keloid formation at the site of an old incision b) Facial acne c) Facial lesions associated with herpes simplex d) Psoriasis

a) Keloid formation at the site of an old incision

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis? a) Stratum corneum b) Stratum lucidum c) Stratum granulosum d) Stratum germinativum

a) Stratum corneum

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 a) hypothyroidism. b) hyperthyroidism. c) infectious conditions. d) hypoparathyroidism.

a) hypothyroidism.

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of a) macules. b) papules. c) plaques. d) bulla.

a) macules.

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? a) Psoriasis b) Acne c) Varicella d) Herpes simplex

b) Acne

The student nurse learns that examining the skin can do all of the following except? a) Reveal overhydration b) Allow early identification of neurologic deficits c) Identify physical abuse d) Allow early identification of potentially cancerous lesions

b) Allow early identification of neurologic deficits

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? a) Borders well demarcated b) Asymmetrical shape c) Color is uniform d) Diameter less than 1/8 of an inch

b) Asymmetrical shape

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs? a) a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution b) a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution c) a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution d) a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter greater than 6 mm; e = evolution

b) a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply. a) the loss of skin turgor as a result of aging b) a cancerous skin lesion located on the back c) presence of a systemic disease like measles d) a rash triggered by taking the medication ibuprofen e) a reddened area on the heel that indicates a potential risk for pressure ulcer formation

b) a cancerous skin lesion located on the back c) presence of a systemic disease like measles d) a rash triggered by taking the medication ibuprofen e) a reddened area on the heel that indicates a potential risk for pressure ulcer formation

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? a) Type b) Color c) Distribution d) Arrangement

c) Distribution

The nurse is preparing to examine a client's skin. What would the nurse do next? a) Ensure that the room is hot to prevent chilling. b) Wear gloves when preparing to inspect the skin and nails. c) Expose only the body part that is being examined. d) Have the client remove clothing from the upper body.

c) 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? a) Allow the client to pray before the examination b) Let the client remained fully dressed for the examination c) Have a nurse who is the same sex as the client examine him d) Avoid asking any questions regarding the client's lifestyle

c) Have a nurse who is the same sex as the client examine him

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? a) It is likely to be related to an exposure to a chemical. b) It is likely to be related to an allergic reaction. c) It is likely to be related to her lupus. d) It should not cause any problems.

c) It is likely to be related to her lupus.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown? a) Eschar on an area near a bony prominence b) Excessive sweating on a dependent body region c) Skin that feels boggy on palpation d) Loss of the dermis

c) Skin that feels boggy on palpation

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate? a) The elderly should only bathe or shower once a week b) The elderly should bathe or shower daily but use lots of moisturizer c) The elderly should bathe or shower only every 2 to 3 days d) The elderly should bathe or shower once every 2 weeks

c) The elderly should bathe or shower only every 2 to 3 days

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? a) Sunlight b) Artificial light c) Wood's light d) Flashlight

c) Wood's light

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 a) plaque. b) macule. c) papule. d) patch.

c) papule.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's a) nodules. b) bullae. c) vesicles. d) wheals.

c) vesicles.

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? a) "Has anyone in your family ever been diagnosed with skin cancer?" b) "Have you ever been assessed for diabetes?" c) "What dietary supplements do you usually take?" d) "Do you take steroid medications on a regular basis?"

d) "Do you take steroid medications on a regular basis?"

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? a) Repeated sunburns in childhood may explain the presence of some of your moles. b) "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." c) "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." d) "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

d) "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

The nurse recognizes that which client is at greatest risk for the development of skin cancer? a) 28-year-old Caucasian male who works in a paper mill b) 45-year-old female with 10 year history of cigarette smoking c) 15-year-old female with facial freckles d) 55-year-old male who lived in California for 20 years

d) 55-year-old male who lived in California for 20 years

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? a) Squamous cells b) Sweat glands c) Subcutaneous tissue d) Sebum production

d) Sebum production