Chapter 14: Assessing Skin, Hair, & Nails
Which statement by a client about the skin needs validation by the collection of objective data by the nurse?
"My feet hurt and are always cold to the touch"
The nurse recognizes that which client is at greatest risk for the development of skin cancer?
55-year-old man who lived in California for 20 years
A nurse cares for a patient with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Broken with the presence of a blister
Which clinical manifestation should the nurse expect to find in a client with edema?
Decreased skin mobility. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched.
A nurse is working with a 13-year-old boy who complains that he has become 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?
Dermis
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
Document the findings in the client's record as normal
A client presents to the health care clinic with reports of new onset of generalized hair loss for the last 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
Hypothyroidism
A mother brings her child to the health care clinic and reports that her son has a four day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
Impetigo
A nurse is instructing a client how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
In a clustered configuration, lesions are grouped together; an example is herpes simplex.
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
In an annual configuration, the lesion is circular; an example is tinea corporis.
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.
Itching; bleeding of a mole; asymmetrical; change in size
A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.
Keep the room door closed; wear gloves when palpating lesions; have the client remove his toupee; use sunlight when possible to inspect the skin
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.
Largest organ in the body; helps make vitamin D in the body; aids in maintaining body temperature; protects against damage to the body from sunlight
Which of the following substances is the major determinant of skin color?
Melanin
A client reports feeling shortness of breath. Which area of the body should the nurse inspect for the presence of cyanosis?
Perioral. Cyanosis makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival areas. This area does not have thick skin.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
Psoriasis, fungal infections, trauma
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that it has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?
Risk for impaired skin integrity because of the presence of thickened toenails that may cause damage to the epidermis of the skin on the lower extremities.
A client presents to the health clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?
Skin warm and dry to the touch
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
Spooning
A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?
This occurs in clients with clubbing which occurs from hypoxia to the tissue secondary to smoking.
"Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question?
To determine the clients risk for pressure ulcers.
How should the nurse palpate the skin of a client to assess its texture?
Touch with the palmar surface of the three middle fingers.
A nurse implements which skin assessment to determine the presence of dehydration in a client?
Turgor
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?
Vesicle
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to a fungal infection.
A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?
A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple.
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.
Ineffective individual coping; anxiety; disturbed body image
A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?
Nail problems can be caused by an underlying systemic illness
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. What is an ABCDE characteristic of malignant melanoma?
A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.
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.
During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?
Document this as a normal finding
A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?
Fingers and toes
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?
Have a nurse who is the same sex as the client examine him
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?
Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones.
Which area of the body should the nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?
Under the breast