CH 55 Med Surg Assessment of integumentary Function

a patient has a serum bilirubin concentration of 3 mg/100 mL. which will the nurse observe when performing a skin assessment on this patient?

jaundice

the epidermis is composed of three types of cells: __, __, and __?

keratinocytes merkel cells langerhans cells

a patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. how will the nurse document this finding?

lichenification

alopecia

loss of hair from any cause

describe how the production of melanin is controlled?

melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte stimulating hormone

the nurse observes an African American patient with a large hypertrophied area of scar tissue on the left ear lobe. which does the nurse document this finding as?

Keloid

the nurse is applying a cold towel to a patient neck to reduce body heat. how will the nurse determine that the heat is reduced?

conduction

hypopigmentation

decrease in the melanin of the skin, resulting in a loss of pigmentation

langerhans cells

dendritic clear cells in the epidermis that carry surface receptors from immunoglobulin and complement and that are active participants in delayed hypersensitivity of the skin

when assessing the skin of an older adult, which major age-related changes are seen in the skin?

dryness wrinkling uneven pigmentation various proliferative lesions cellular changes associated with aging including a thinning at the junction of the dermis and epidermis

there are three layers of the skin: __, __, and __?

epidermis dermis subcutaneous tissue

sebum

fatty secretion of the sebaceous glands

sebaceous glands

glands that exist within the epidermis and secrete sebum to keep the skin soft and pliable

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. which question would be most appropriate to ask the patient to identify a potential cause of the skin discoloration?

have you been eating a large amount of carotene-rich foods

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

herpes zoster

the nurse should know that clubbing of the nails is usually an indicator of __?

hypoxia

hyperpigmentation

increase in the melanin of the skin, resulting in an increase in pigmentation

the epidermis is almost completely replaced every __?

2 to 3 weeks

the nurse is caring for an adult patient with a body temperature within normal range. which is the approximate insensible water loss per day in this patient?

600 mL/day

skin needs to be exposed to sunlight to manufacture vitamin __?

D

vitiligo

a localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches

the subcutaneous tissue, which is primarily composed of __ tissue, has a major role in __ regulation?

adipose temperature

the term used to describe hair loss is __ ?

alopecia

keratin

an insoluble fibrous protein that forms the outer layer of the skin

keratin

an insoluble, fibrous protein that forms the outer skin layer

dermatosis

any abnormal skin condition

keratinocytes

arising from the innermost layer of the epidermis, synthesize the insoluble protein, keratin

echymosis

bleeding into the skin and tissue, initially evidenced by varied color (ex purple, black) that gradually fades to green, yellow, or brown over time

the nurse is assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. which disorder does the nurse identify correlates with this assessment finding?

carbon monoxide poisoning

merkel cells

cells of the epidermis that play a role in transmission of sensory messages

melanocytes

cells of the skin that produce melanin

a patient is visiting the health care provider to determine what type of allergy is causing a rash. which type of testing will be appropriate in order to determine the cause of this finding?

patch test

petechiae

pinpoint red spots that appear on the skin as a result of blood leakage into the skin

the nurse is assessing a patient with a primary skin lesion called a macule. which does the nurse identify is a clinical example of this lesion?

port-wine stains

the nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand of a patient that bleed when picked off. which skin disorder correlates with this assessment finding?

psoriasis

the nurser is assessing the fingernails of a patient at the clinic. the nurse observes pitting on the surface of the nail. which disorder is this finding indicative of?

psoriasis

the nurse is assessing a patient with risk factors related to human immune deficiency virus (HIV). which assessment finding does the nurse identify as a manifestation of the disease?

purplish cutaneous lesions

__, __, and __ are the major physical processes involved in loss of heat from the body to the environment?

radiation conduction convection

telangiectasia

red marks on the skin caused by distention of the superficial blood vessels

erythema

redness of the skin caused by congestion of the capillaries

erythema

redness of the skin, caused by dilation of the capillaries due to injury, irritation, inflammation, or various skin conditions

jaundice can be first observed by examining the __ and __?

sclera mucous membrane

__ and __ are two types of skin glands?

sebaceous sweat

hirsutism

the condition of having excessive hair growth

describe what function the hair of the skin serves?

the hair of the skin provides thermal insulation in mammals. this function is enhanced during cold or fright by piloerection, caused by contraction of the tiny erector muscles attached to the hair follicle

what is the function of the receptors endings of the nerves in the skin?

the receptors endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. they sense temperature, pain, light touch, and pressure

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

the skin is ashen gray and dull

melanin

the substance responsible for coloration of the skin

wood light

ultraviolet light used for diagnosing skin conditions

rete ridges

undulation and furrows that appear at the lower edge of the epidermis at the dermal junction where these two skin layers are cemented together

telangiectasias

vascular structures; red marks on the skin caused by distention of the superficial blood vessels

the nurse assesses a patient and observes a herpes simplex/zoster skin lesion. how will the nurse document this lesion?

vesicle