Chap 22 Assessment of the Hair, Skin, and Nails

Which teaching points would the nurse be sure to share with a client scheduled for a punch biopsy? Select all that apply. a.) A local anesthetic will be injected into the site. b.) A circular instrument will cut out a tissue sample. c.) The site will always require suturing after the procedure. d.) You will have a scar similar to a healed surgical incision. e.) Antibiotic ointment may be prescribed to reduce the risk for infection. f.) Keep a dry dressing on the site until your sutures are removed.

a.) A local anesthetic will be injected into the site. b.) A circular instrument will cut out a tissue sample. e.) Antibiotic ointment may be prescribed to reduce the risk for infection.

When the nurse takes a client's medication history after noting the presence of ecchymoses, which types of drugs are of concern? SATA a.) Aspirin products b.) Oral antidiabetic agents c.) Anticoagulants d.) Long-term corticosteroids e.) Histamine blockers f.) Short-term loop diuretics

a.) Aspirin products c.) Anticoagulants d.) Long-term corticosteroids

Which roles of a client's intact skin will the nurse consider most important? SATA a.) Body temperature regulation b.) Protection against infection c.) Providing nutrition to underlying cells d.) Maintaining fluid and electrolyte balance e.) Sensory function to provide comfort f.) Aid in elimination of excess CO2

a.) Body temperature regulation b.) Protection against infection d.) Maintaining fluid and electrolyte balance e.) Sensory function to provide comfort

What is the most accurate method for the nurse to use when assessing cyanosis in a dark-skinned client admitted for pneumonia? a.) Check the conjunctivae and nail beds for a bluish tinge color. b.) Observe for asymmetrical skin color changes c.) Auscultate for decreased breath sounds in the lung fields. d.) Inspect the palms and soles for a yellow-tinged color.

a.) Check the conjunctivae and nail beds for a bluish tinge color.

Which assessment techniques would the nurse use when checking a client with dark skin for inflammation? SATA a.) Compare affected area with nonaffected area for increased warmth. b.) Examine the nail beds, palms, and soles for blue tinge. c.) Compare the skin color of affected area with the same area on the opposite side. d.) Examine the sclera nearest to the iris rather than the corners of the eye. e.) Check the oral mucosa or conjunctive for petechiae. f.) Examine the skin of the affected area to see if it is shiny, taut, or pits with pressure.

a.) Compare affected area with nonaffected area for increased warmth. c.) Compare the skin color of affected area with the same area on the opposite side. f.) Examine the skin of the affected area to see if it is shiny, taut, or pits with pressure.

Which factors are included in the ABCDE features associated with skin cancer? SATA a.) Evolving or changing of any feature b.) Diameter greater than 5 mm c.) Crusting, bleeding, or itching d.) Color variation within a lesion e.)Border regularity f.) Asymmetry of shape

a.) Evolving or changing of any feature d.) Color variation within a lesion f.) Asymmetry of shape

What is the best method for the nurse to complete a client's skin assessment while effectively using time management? a.) Examine the client's skin while bathing or assisting with hygiene b.) Perform the examination when the client willingly consents and agrees c.) Question the assistive personnel (AP) who has completed the client's bath d.) Check the skin assessment from the previous shift and look for changes

a.) Examine the client's skin while bathing or assisting with hygiene

What does the nurse suspect when a client has skin that is tight and shiny over the lower extremities? a.) Fluid retention and edema b.) Early stage of infection c.) Early signs of poor circulation d.) Bleeding into the skin

a.) Fluid retention and edema

Which actions would the nurse take when a client has decreased eccrine and apocrine gland activity? SATA a.) Instruct the client to use soap with a high fat content. b.) Assess skin for size and shape of pores or comedones. c.) Use the oral mucosa to assess for cyanosis d.) Teach the client to avoid frequent bathing with hot water. e.) Suggest wearing hats to prevent heat loss in cold weather. f.) Encourage the client to apply moisturizers after bathing.

a.) Instruct the client to use soap with a high fat content. d.) Teach the client to avoid frequent bathing with hot water. f.) Encourage the client to apply moisturizers after bathing.

For which conditions, which could contribute to overall hygiene, would the nurse assess where a client presents with matted hair, body odor, and soiled clothes? SATA a.) Intact sensory functions (e.g., sight, smell) b.) Range of motion and strength c.) Access to shower and laundry d.) Client's currently prescribed drugs e.) Perception of his or her appearance f.) Knowledge (memory) of hygiene care

a.) Intact sensory functions (e.g., sight, smell) b.) Range of motion and strength c.) Access to shower and laundry d.) Client's currently prescribed drugs e.) Perception of his or her appearance f.) Knowledge (memory) of hygiene care

For which client will the nurse instruct the assistive personnel (AP) to use a lift sheet when assisting with movement in bed? a.) Older adult client on steroids with thin, fragile skin b.) Client with type 2 diabetes and delayed wound healing c.) Obese client with moisture in skin folds d.) Client with a substance use problem

a.) Older adult client on steroids with thin, fragile skin

Age-related changes in the integumentary system include decreases in which factors? SATA a.) Rate of nail growth b.) Thickness of epidermis c.) Dermal blood flow d.) Thickening of the nail e.) Vitamin D production f.) Epidermal permeability

a.) Rate of nail growth b.) Thickness of epidermis c.) Dermal blood flow e.) Vitamin D production

Which preprocedural teaching will the nurse provide for a client suspected of a bacterial cellulitis? a.) The primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture. b.) The crusts will be removed with normal saline, then the underlying exudate will be swabbed for a specimen. c.) A smear will be obtained from the base of the lesion and examined in the lab under a microscope. d.) A cotton-tipped applicator will be used to obtain vesicle fluid from intact lesions.

a.) The primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture.

Which specimen would the nurse instruct the assistive personnel (AP) to immediately place on ice and transport to the lab as soon as possible? a.) Vesicle fluid taken by sterile technique and placed in a viral culture tube b.) Punch biopsy performed with sterile technique for collection of a tissue piece c.) Exudate taken by sterile technique and swabbed on a bacterial culture medium d.) Aspirate taken by sterile technique and placed in a bacterial culture tube

a.) Vesicle fluid taken by sterile technique and placed in a viral culture tube

Which questions would the nurse ask to determine if a client with a rash is having a new allergic reaction? SATA a.) "Is your skin usually flakey or dry?" b.) "Are you taking any new medications?" c.) "Have you been using any different soaps, cosmetics, or lotions?" d.) "Have you noticed any bruises or brownish discolorations?" e.) "Have you been exposed to any new cleaning solutions?" f.) "Have you had any recent changes in your diet?"

b.) "Are you taking any new medications?" c.) "Have you been using any different soaps, cosmetics, or lotions?" e.) "Have you been exposed to any new cleaning solutions?" f.) "Have you had any recent changes in your diet?"

When caring for an older adult, what skin changes would cause the nurse to keep the client's room warmer? a.) Decreased number of active melanocytes b.) Decreased layer of subcutaneous fat c.) Decreased thickness or epidermis d.) Decreased sebum production

b.) Decreased layer of subcutaneous fat

Which assessment technique would the nurse use to check the skin turgor of a client who is at risk for hypovolemia? a.) Push on the skin with thumbs and observe for blanching. b.) Gently pinch the skin on the back of the hand and observe for tenting. c.) Brush the skin surface back and forth while observing for flaking. d.) Push on the skin over the tibia and observe for depth of indentation.

b.) Gently pinch the skin on the back of the hand and observe for tenting.

Which technique does the nurse use to assess the "..health of the nails of a client with very dark skin." a.) Obtain a color chart to identify the normal color of nails for dark-skinned clients. b.) Gently squeeze the end of the finger exerting downward pressure, then release it. c.) Observe the nail bed for a pale pink color and a shiny, smooth surface d.) Soak the fingertips in warm water, then gently push back cuticles.

b.) Gently squeeze the end of the finger exerting downward pressure, then release it.

What diagnostic test does the nurse prepare a client for when the PHCP prescribes a test to determine if the client has a fungal infection of the skin? a.) Punch biopsy b.) KOH test c.) Shave biopsy d.) Wood's light exam

b.) KOH test

Which assessment finding does the nurse use as the best indicator of a client's healthy nails? a.) Nail bed color is normal for the client. b.) Nail bed blanches with gentle pressure c.) Nails are well-groomed and nicely shaped. d.) Nail surface is smooth and transparent.

b.) Nail bed blanches with gentle pressure

What changes in color does the nurse expect when assessing a client with polycythemia vera? SATA a.) Brown localized skin areas b.) Reddish blue generalized skin color c.) Red color localized to area of involvement d.) Dark red nail beds e.) Diffuse blue discoloration of nails f.) Yellow to brown nail beds

b.) Reddish blue generalized skin color d.) Dark red nail beds

Which is the best rationale for the nurse to use to encourage a client to seek treatment for dandruff? a.) Dandruff is a cosmetic problem but appearance is important to self-esteem. b.) Severe dandruff is caused by excessive oiliness and can cause hair loss. c.) Dandruff flakes are caused by dry scalp and suggest possible dehydration. d.) Brushing your hair everyday can prevent dandruff but may weaken follicles

b.) Severe dandruff is caused by excessive oiliness and can cause hair loss.

Which areas would the nurse give special attention to when assessing an obese older adult? a.) Mucous membranes b.) Skinfolds c.) Scalp d.) Nails

b.) Skinfolds

What priority instruction would the nurse provide the assistive personnel (AP) who is to bathe a client with skin that is not intact and is draining? a.) Save any fingernail clippings or hair samples for testing. b.) Wear clean gloves and use Standard Precautions. c.) Have a second AP assist you to get the client out of bed. d.) Let the client soak in the tub for 15 minutes before rinsing.

b.) Wear clean gloves and use Standard Precautions.

What is the best site for the nurse to assess skin for dehydration in an older adult client? a.) Forearm b.) Mid-thigh c.) Forehead d.) Lower abdomen

c.) Forehead

What area of a dark-skinned client would the nurse assess for petechiae when the client is at risk for thrombocytopenia? a.) Palmar surface b.) Anterior chest c.) Oral mucosa d.) Periorbital area

c.) Oral mucosa

Which laboratory test would the nurse be sure to check when finding a large area of ecchymoses while assessing a client? a.) Hemoglobin level b.) White blood cell count c.) Platelet count d.) International normalized ratio (INR)

c.) Platelet count

Which skin disorder is most associated with a familial predisposition? a.) Scabies b.) Cellulitis c.) Psoriasis d.) Ringworm

c.) Psoriasis

What is the best place for the nurse to examine a fair-skinned client for yellow discoloration when jaundice is suspected? a.) Palms b.) Soles c.) Sclera d.) Nail beds

c.) Sclera

For a decrease in which Integumentary factor would the nurse avoid taping the skin on an older adult client? a.) Vitamin D production b.) Dermal blood flow c.) Thickness of epidermis d.) Melanocyte activity

c.) Thickness of epidermis

What is the best method for a nurse to collect a superficial specimen from a raised lesion for a suspected fungal infection in a client's groin? a.) Express exudate from a lesion and use a sterile swab to collect fluid. b.) Obtain a small sample of tissue from the groin using needle biopsy. c.) Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen. d.) Have the PHCP do a deep excision with a scalpel followed by closure with sutures.

c.) Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen.

Which question would the nurse ask when assessing a female client who reports an unusual increase in facial hair? a.) "Does your skin seem unusually dry and flakey?" b.) "Have you noticed any bruising or unusual bleeding?" c.) "Are you having trouble with urination or moving your bowels?" d.) "Have you noticed any deepening of your voice quality?"

d.) "Have you noticed any deepening of your voice quality?"

When regulating body temperature, how much evaporative water can the eccrine sweat glands lose in one day? a.) 500-600 mL/day b.) 700-900 mL/day c.) 2-4 L/day d.) 10-12 L/day

d.) 10-12 L/day

Which term would the nurse use to document a client's skin lesions that are widespread involving most of the body? a.) Circumscribed b.) Universal c.) Linear d.) Diffuse

d.) Diffuse

Which terms would the nurse use to document a client's rash that is red, raised, and itching over most of his or her body? a.) Red, macular, lichenified b.) Cyanotic, annular, popular c.) Red, universal, circinate d.) Erythematous, diffuse, pruritic

d.) Erythematous, diffuse, pruritic

Which skin changes does the nurse expect to see in an older adult client as a result of a decreased number of active melanocytes? a.) Increased skin transparency b.) Decreased skin firmness and elasticity c.) Slowed and decreased healing d.) Increased sensitivity to sun exposure

d.) Increased sensitivity to sun exposure

Which skin assessment finding in an older adult client is most important for the nurse to report to the primary health care provider (PHCP) for follow-up? a.) Presence of cherry hemangiomas b.) Multiple brownish liver spots on the arms c.) Dry and flakey skin on the lower extremities d.) Irregular light-brown macule (6.5 cm) on the right scapula

d.) Irregular light-brown macule (6.5 cm) on the right scapula

What is the priority medical/surgical concept when the nurse assesses a client and finds reddened scratch marks on the right forearm? a.) Infection b.) Immunity c.) Cellular regulation d.) Tissue integrity

d.) Tissue integrity

What skin manifestations does the nurse expect to observe in a client during impending shock? a.) Dry, flushed appearance b.) Poor turgor with a rough texture c.) Bluish color that blanches d.) White, pale, cool skin

d.) White, pale, cool skin

Which equipment would the nurse obtain to assist the PCP in examining a light-skinned client for evaluation of skin pigment changes? a.) Glass slides b.) Biopsy tray c.) Bright nonfluorescent light d.) Wood's lamp

d.) Wood's lamp