chap 11

Tinea versicolor Explanation: This is a typical description of tinea versicolor. The information that the client is sweating more also helps support this diagnosis, because tinea is a fungal infection and promoted by moisture

A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis? Atopic eczema Pityriasis rosea Tinea versicolor Psoriasis

Explanation: Paronychia is an infection of the cuticle. That is the area on the diagram that is affected.

A client is diagnosed with paronychia. Which part of the diagram should the nurse assess for this health problem?

Inspect the area Explanation: If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

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

Braden scale Explanation: Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? Head-to-toe assessment Braden scale Newton scale Norton scale

Location Distribution pattern Elevation Color Explanation: When examining a client's skin lesions, the nurse should note: anatomical location and distribution, patterns and shapes, types of lesions, color, and elevation. The condition of the surrounding skin is not included in the documentation of a client's lesions.

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.) Color Elevation Condition of surrounding skin Location Distribution pattern

subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

Connecting the skin to underlying structures is/are the subcutaneous tissue. dermis layer. papillae. sebaceous glands.

dermis. Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. keratinized tissue. dermis. eccrine glands.

vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

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

stage II. Explanation: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as stage IV. stage II. stage III. stage I.

The client may have been abused. Explanation: Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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

vesicles. Explanation: Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

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 wheals. vesicles. bullae. nodules.

use two fingers to pinch the skin under the clavicle. Explanation: To assess turgor, gently pinch the skin over the clavicle with two fingers.

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

fainting Explanation: Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?fainting vomiting diarrhea diaphoresis

hypothyroidism. Explanation: Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

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 hypoparathyroidism. hyperthyroidism. hypothyroidism. infectious conditions.

3 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? 1 4 3 2

Location Distribution pattern Elevation Color Explanation: When examining a client's skin lesions, the nurse should note: anatomical location and distribution, patterns and shapes, types of lesions, color, and elevation. The condition of the surrounding skin is not included in the documentation of a client's lesions.

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.) Distribution pattern Color Location Condition of surrounding skin Elevation

fissures. Explanation: Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of ulcers. erosion. scales. fissures.

stage II. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

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 stage IV. stage III. stage I. stage II.

Vitiligo Explanation: Vitiligo is characterized by discrete areas of depigmentation. Albinism is a generalized absence of pigment, and striae are often known as stretch marks. Angiomas are small, raised skin lesions

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? Vitiligo Striae Angiomas Albinism

Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.

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

hypoxia. Explanation: Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia.

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of anemia. hypoxia. trauma. infection.

A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Skin warm and dry to the touch Explanation: Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin? Dry and flaky skin in the winter months Denies any skin color changes Small lesion left forearm for one month Skin warm and dry to the touch

Peripheral cyanosis Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what? Reynaud disease Central cyanosis Neurofibromatosis Peripheral cyanosis

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. Explanation: Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is: ineffective individual coping related to changes in appearance. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. anxiety related to loss of outdoor activities and altered skin appearance. dry flaking skin and dull dry hair as a result of disease.

high Explanation: This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.

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? high mild moderate negligible

Stratum corneum Explanation: The epidermis consists of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum, in that order.

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? Stratum granulosum Stratum corneum Stratum lucidum Stratum germinativum

Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

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? Stage I Stage II Stage III Stage IV

Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

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? Stage II Stage IV Stage I Stage III

The elderly should bathe or shower only every 2 to 3 days Explanation: Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

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? The elderly should bathe or shower daily but use lots of moisturizer The elderly should bathe or shower only every 2 to 3 days The elderly should only bathe or shower once a week The elderly should bathe or shower once every 2 weeks

The elderly should bathe or shower only every 2 to 3 days Explanation: Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

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? The elderly should bathe or shower daily but use lots of moisturizer The elderly should only bathe or shower once a week The elderly should bathe or shower once every 2 weeks The elderly should bathe or shower only every 2 to 3 days

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Explanation: Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

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? "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." Repeated sunburns in childhood may explain the presence of some of your moles. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Explanation: Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question

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? Repeated sunburns in childhood may explain the presence of some of your moles. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

The client is consistently incontinent of urine. Explanation: The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client has a full-time caregiver. The client adheres to a vegetarian diet. The client has a surgical diagnosis. The client is consistently incontinent of urine.

When palpating lesions on the client's skin Explanation: Gloves are necessary when palpating any lesions because there is a risk of being exposed to drainage. Gloves are not normally necessary when palpating clients' nail beds, hair, or skin texture.

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? When palpating lesions on the client's skin When palpating the client's hair When palpating the client's nail beds for texture and capillary refill When palpating the texture of the client's skin

There is a non-blanching reddened area on the client's coccyx region. Explanation: Non-blanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? There is a generalized rash on the client's lower back and buttocks. There is noticeable bruising on and around the client's coccyx region. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. There is a non-blanching reddened area on the client's coccyx region.

There is a non-blanching reddened area on the client's coccyx region. Explanation: Non-blanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? There is a non-blanching reddened area on the client's coccyx region. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. There is a generalized rash on the client's lower back and buttocks. There is noticeable bruising on and around the client's coccyx region.

Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature Explanation: The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. Helps make vitamin D in the body Circulates blood throughout the body Largest organ of the body Aids in maintaining body temperature Involved in digestion of food Protects against damage to the body from sunlight

Dermis Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

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? Stratum corneum Stratum lucidum Dermis Epidermis

Cushing's disease Explanation: Hirsutism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Cushing's disease Lupus erythematosus Iron deficiency anemia Basal cell carcinoma

Cushing's disease Explanation: Hirsutism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Iron deficiency anemia Lupus erythematosus Cushing's disease Basal cell carcinoma

Alopecia areata Explanation: This is a typical description for alopecia areata. There are no risk factors for trichotillomania or traction alopecia. The physical examination is not consistent with tinea capitis, because the skin is intact.

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? Traction alopecia Tinea capitis Alopecia areata Trichotillomania

The client has chronic hypoxia Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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? The client has asthma The client has COPD The client has melanoma The client has chronic hypoxia

The client has chronic hypoxia Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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? The client has chronic hypoxia The client has melanoma The client has COPD The client has asthma

Vesicle Explanation: Herpes zoster (shingles) is characterized by grouped vesicular skin eruptions along a cutaneous sensory nerve line. The vesicles typically are less than 0.5 cm. Elevated nevi or warts would be noted as papules. Bulla would be vesicles greater than 0.5 cm. Crust is a dried residue of serum, blood, or pus on the skin, such as what is left after a vesicle ruptures.

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? Papule Vesicle Bulla Crust

Sebum production Explanation: Sebum production decreases with age, increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

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? Subcutaneous tissue Sweat glands Squamous cells Sebum production

"These are considered a normal age-related change in the skin." Explanation: Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "It means you have skin cancer and need to have them removed." "These are considered a normal age-related change in the skin." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."

Urticaria or hives Explanation: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

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? Psoriasis Insect bites Urticaria or hives Purpura

It is likely to be related to her lupus. Explanation: A "palpable purpura" is usually associated with a vasculitis. This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and mimic many other diseases. While allergic and chemical exposures may be a possible cause of the rash, this client's SLE should make the nurse consider vasculitis.

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? It is likely to be related to an allergic reaction. It should not cause any problems. It is likely to be related to her lupus. It is likely to be related to an exposure to a chemical.

stage II. Explanation: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as stage IV. stage III. stage II. stage I.

stage II. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

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 stage I. stage II. stage III. stage IV.

Vitiligo Explanation: Vitiligo is characterized by discrete areas of depigmentation. Albinism is a generalized absence of pigment, and striae are often known as stretch marks. Angiomas are small, raised skin lesions.

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? Striae Angiomas Vitiligo Albinism

"Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

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? "Has anyone in your family ever been diagnosed with skin cancer?" "Have you ever been assessed for diabetes?" "What dietary supplements do you usually take?" "Do you take steroid medications on a regular basis?"

"Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

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? "Have you ever been assessed for diabetes?" "Has anyone in your family ever been diagnosed with skin cancer?" "What dietary supplements do you usually take?" "Do you take steroid medications on a regular basis?"

Vasoconstriction Explanation: Peripheral cyanosis may be a local problem resulting from vasoconstriction. A cardiopulmonary etiology is unlikely in a client who enjoys overall good health.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? Hyperglycemia Hypoxemia Cardiopulmonary insufficiency Vasoconstriction

15 Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 258. Patient scores 14 or above on Norton Scale or 18 or above on Braden Scale if normal

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 15 9 13 11

Expose only the body part that is being examined. Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

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

Expose only the body part that is being examined. Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

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

Excessive collagen formation Explanation: Keloids are caused by excessive collagen formation during the healing process, not from continuous trauma, decreased subcutaneous tissue, or inadequate circulation.

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? Excessive collagen formation Inadequate circulation Decreased subcutaneous tissue Continuous trauma

Are you allergic to foods, medications, or other substances? Explanation: The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information such as a history of a previous or similar rash and measures to address the itching.

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? "Does anyone else in your family have a rash like this?" "What have you been doing to control the itching?" "Have you ever had a rash like this before?" Are you allergic to foods, medications, or other substances?

Are you allergic to foods, medications, or other substances? Explanation: The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information such as a history of a previous or similar rash and measures to address the itching.

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? Are you allergic to foods, medications, or other substances? "Does anyone else in your family have a rash like this?" "Have you ever had a rash like this before?" "What have you been doing to control the itching?"

Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding.

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

Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding.

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

pulse oximetry Explanation: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? heart sounds pulse oximetry bowel sounds body temperature

Pressure ulcer Explanation: An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Cherry angioma Cutaneous horn Seborrheic keratosis Pressure ulcer

Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

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

Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

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

Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

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

Under the breast Explanation: The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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? Anterior chest Upper abdomen On the neck Under the breast

Dermis Explanation: The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Connective layer Dermis Epidermis Subcutaneous layer

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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

Terminal hair growth on chin Explanation: Older adult women may have terminal hair growth on the chin owing to hormonal changes. Hair in the older adult is typically thin and feels coarser and drier with aging. Pubic, axillary, and body hair also decrease with aging. Copper-red colored hair is found in African American children with severe malnutrition.

Which of the following findings related to hair would the nurse most likely assess in an older adult female client? Thick elastic scalp hair Terminal hair growth on chin Increased pubic hair Copper-red color

caused by aging of the skin in older adults. Explanation: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

The client's perception affects the approach and effectiveness in treating the skin condition Explanation: The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies

Why is it important for the nurse to ask the client what they think caused a skin condition? The client's perception affects the approach and effectiveness in treating the skin condition Doing so encourages the client to use home remedies to reduce medical cost The nurse can alleviate the client's fears about what caused the skin condition Doing so allows the client to decide what treatment is the best course of action

Can be caused by an underlying systemic illness Explanation: Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problem because they can be damaging to a person's self image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? May affect a person's body image negatively Local irritation can cause damage to the nail bed Abnormalities may be a sign of poor hygiene Can be caused by an underlying systemic illness