Chapter 14: Assessing Skin, Hair, and Nails

______ fluorescence indicates fungal infection.

blue-green

The epidermis is replaced how often?

every 3-4 weeks

A localized collection of blood creating an elevated ecchymosis. It is associated with trauma.

hematoma

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

high

______ clients often report dry, itchy skin.

obese

______ is seen in psoriasis.

pitting

Examples of ______ include psoriasis (psoriasis vulgaris) and actinic keratosis.

plagues

______ arise from normal skin due to irritation or disease.

primary lesions

Hair on the head ______ the scalp, provides ______, and allows for ______.

protect, insulation, self-expression

Pus-filled vesicle or bulla. Examples include acne, impetigo, furuncles, and carbuncles.

pustule

What is the largest organ in the body?

skin

Puberty initiates the growth of additional ______ hair in both sexes on the axillae, perineum, and legs.

terminal

______ hair (particularly scalp and eyebrows) is longer, generally darker, and coarser than vellus hair.

terminal

______ refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched.

turgor

Deep wound due to loss of skin.

ulcer

______, reddish-bluish lesions, are seen with bleeding, venous pressure, aging, liver disease, or pregnancy.

vascular lesions

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Linear Annular Clustered Discrete

clustered

What layer of the skin is the outer layer and serves a purpose of protection?

epidermis

The skin is composed of what three layers?

epidermis, dermis, and subcutaneous tissue

______ (facial hair on females) is a characteristic of Cushing disease and polycystic ovary syndrome (PCOS) and results from an imbalance of adrenal hormones or it may be a side effect of steroids.

hirsutism

A client with a zosteriform rash has a rash that has lesions distributed over a large body area appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion is distributed along a dermatome is distributed equally on both sides of the body

is distrubuted along a dermatome

______ is characterized by yellow skin tones, ranging from pale to pumpkin, particularly of the sclera, oral mucosa, palms, and soles.

jaundice

Excessive scar, elevated.

keloid

Elevated, solid, palpable mass that extends deeper into dermis than a papule.

nodule and tumor

______ are 0.5-2 cm and circumscribed; ______ are greater than 1-2 cm and do not always have sharp borders.

nodules; tumors

______ (concave) may be present with iron deficiency anemia

spoon

The ______ stores fat as an energy reserve, provides insulation to conserve internal body heat, serves as a cushion to protect bones and internal organs, and contains vascular pathways for the supply of nutrients and removal of waste products to and from the skin.

subcutaneous tissue

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

the client has chronic hypoxia

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? Insect bites Urticaria or hives Psoriasis Purpura

urticaria or hives

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

vellus

Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include urticaria (hives) and insect bites.

wheal

If you suspect a fungus, shine a ______ (an ultraviolet light filtered through a special glass) on the lesion.

wood light

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? Moist and smooth Moist and rough Dry and smooth Dry and rough

dry and rough

Round or irregular macular lesion that is larger than petechial lesion. The color varies and changes: black, yellow, and green hues. It is secondary to blood extravasation and associated with trauma and bleeding tendencies. Bruising.

ecchymosis

What are the two types of sweat glands?

eccrine and apocrine

The ______ are located over the entire skin. Their primary function is secretion of sweat and thermoregulation, which is accomplished by evaporation of sweat from the skin surface.

eccrine glands

Spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease.

koilonychia

Examples of ______ include keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma.

nodules

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. May be difficult to detect in individuals with dark skin tones.

stage I pressure ulcer

______ hair (peach fuzz) is short, pale, fine, and present over much of the body.

vellus

______ hair provides thermoregulation by wicking sweat away from the body.

vellus

What are the two general types of hair?

vellus and terminal

Circumscribed elevated, palpable mass containing serous fluid. ______ are less than 0.5 cm; ______ are greater than 0.5 cm.

vesicle; bulla

Examples of ______ include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

vesicles

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 nodules. bullae. vesicles. wheals.

vesicles

A generalized loss of pigmentation is seen in ______.

albinism

The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the ______.

cuticle

______ may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas.

cyanosis

Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis.

cyst

______ may indicate local or systemic problems.

lesions

The ______ is a crescent-shaped area located at the base of the nail. It is the visible aspect of the nail matrix.

lunula

Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red).

macule and patch

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

macules

______ are less than 1 cm with a circumscribed border, whereas ______ are greater than 1 cm, and may have an irregular border. Examples include freckles, flat moles, petechiae, rubella (pictured below), vitiligo, port wine stains, and ecchymosis.

macules, patches

______ (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

pallor

Elevated, palpable, solid mass.

papule and plaque

Examples of ______ include elevated nevi, warts, and lichen planus.

papules

______ have a circumscribed border and are less than 0.5 cm; ______ are greater than 0.5 cm and may be coalesced papules with a flat top.

papules; plagues

Round red or purple macule that is 1-2 mm in size. It is secondary to blood extravasation and associated with bleeding tendencies or emboli to skin.

petechia

Examples of ______ include larger lipoma and carcinoma.

tumors

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

acne

Pustules with hair loss in patches are seen in ______, a contagious fungal disease (ring worm).

tinea capitis

______ is velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla.

acanthosis nigricans

The ______ are associated with hair follicles in the axillae, perineum, and areolae of the breasts. They are small and nonfunctional until puberty, at which time they are activated and secrete a milky sweat. The interaction of sweat with skin bacteria produces a characteristic body odor.

apocrine glands

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears greenish. ashen. bluish. olive.

ashen

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister

broken with the presence of a blister

Examples of ______ include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.

bulla

______ can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma

cancerous lesions

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Deoxyhemoglobin Carotene Melanin

carotene

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.

caused by aging of the skin in older adults

Papular and round, red or purple lesion found on the trunk or extremities. It may blanch with pressure. It is a normal age-related skin alteration and usually not clinically significant.

cherry angioma

The older client's skin may feel dryer than a younger client's skin because sebum production ______ with age.

decreases

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

dermis

What is the inner layer of the skin?

dermis

Some nurses believe that using the ______ surfaces of the hands to assess moisture leads to a more accurate result.

dorsal

______ (skin redness and warmth) is seen in inflammation, allergic reactions, or trauma.

erythema

Increased moisture or diaphoresis (profuse sweating) may occur in conditions such as ______.

fever or hyperthyroidism

Nasal hair, auditory canal hair, eyelashes, and eyebrows ______ dust and other airborne debris.

filter

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.

fissures

A reduction in production of pigment results in ______ or ______ hair.

gray, white

Hair develops within a sheath of epidermal cells called the ______.

hair follicle

Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease.

half and half nails

Rough, flaky, dry skin is seen in ______.

hypothyroidism

Pale or cyanotic nails may indicate ______.

hypoxia or edema

The major determinant of skin color is ______.

melanin

Hair color varies and is determined by the type and amount of pigment (______ and ______) production.

melanin, pheomelanin

In women, apocrine secretions are linked with the ______.

menstrual cycle

______ refers to how easily the skin can be pinched.

mobility

The ______ protect the distal ends of the fingers and toes, enhance precise movement of the digits, and allow for an extended precision grip.

nails

Which technique should the nurse use to properly assess a client's skin turgor? Pinch the skin over the clavicle and observe its return to the original shape Palpate the skin on the sternum to determine its flexibility Pinch the skin on the abdomen and observe for color changes Palpate the skin around the umbilicus to assess for intactness

pinch the skin over the clavicle and observe its return to the original shape

The nail body extends over the entire nail bed and has a ______ tinge as a result of blood vessels underneath.

pink

The ______ are attached to hair follicles and, therefore, are present over most of the body, excluding the soles and palms. They secrete an oily substance called sebum that waterproofs the hair and skin.

sebaceous glands

______ arise from changes in primary lesions.

secondary lesions

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.

stage II pressure ulcer

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Bone or tendon is not visible.

stage III pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

stage IV pressure ulcer

Beneath the dermis lies the ______, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles

subcutaneous tissue

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.

unstageable pressure ulcer