Chapter 14: Assessing Skin, Hair, and Nails

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: A. Palmar surfaces B. Vertex C. Eyebrows D. Limbs

Correct response: A. Palmar surfaces Explanation: The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, STRUCTURE AND FUNCTION, p. 249.

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply. A. Fat cells B. Blood vessels C. Lymphatic vessels D. Sweat glands E. Vernix

B. Blood vessels C. Lymphatic vessels D. Sweat glands Explanation: The dermis is the layer of skin below the epidermis. The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, blood vessels, lymph vessels, and nerve endings. It is also the origin of sebaceous glands, sweat glands, and hair follicles. Fat cells are contained in the subcutaneous tissue. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects the infant's skin. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, STRUCTURE AND FUNCTION, p. 248.

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? A. Braden scale B. Head-to-toe assessment C. Norton scale D. Newton scale

Correct response: A. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, BOX 14-3 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: PRESSURE INJURIES, p. 256.

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

Correct response: A. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, STRUCTURE AND FUNCTION, p. 248.

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? A. Document the findings in the client's record as normal B. Monitor the client for additional findings of cystic fibrosis C. Suggest that the client use antiperspirant products D. Assess the client for changes in sensation due to vascular problems

Correct response: A. Document the findings in the client's record as normal Explanation: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, BIOLOGICAL (GENETIC) AND CULTURAL BEHAVIOR VARIATIONS, p. 249.

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 A. fissures. B. scales. C. erosion. D. ulcers.

Correct response: A. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, ABNORMAL FINDINGS 14-4 Secondary Skin Lesions, p. 274.

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? A. high B. mild C. negligible D. moderate

Correct response: A. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, p. 269.

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs? A. a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution B. a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution C. a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution D. a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter greater than 6 mm; e = evolution

Correct response: B. a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution Explanation: This is the correct description for the mnemonic. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, ABNORMAL FINDINGS 14-6 Skin Cancer, p. 276.

When documenting that a client has freckles, the appropriate term to use is A. vesicles B. macules C. patches D. bullae

Correct response: B. macules Explanation: Macules are skin discolorations that are flat, circumscribed, discolored, and less than 1 cm in diameter. An example of a macule is a freckle. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, ABNORMAL FINDINGS 14-3 Primary Skin Lesions, p. 273.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially A. actinic keratoses. B. malignant melanoma. C. squamous cell carcinoma. D. basal cell carcinoma.

Correct response: B. malignant melanoma. Explanation: Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 262.

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client? A. normal age-related changes in hair growth B. patchy, thin hair C. premature graying of hair D. increased facial hair growth

Correct response: B. patchy, thin hair Explanation: The thyroid gland controls metabolism. In hypothyroidism, the slowed metabolism decreases the rate of hair growth, resulting in thin patchy hair. This is more pronounced than typical age-related changes in hair. Hypothyroidism does not cause premature graying of hair. Increased facial hair is seen in Cushing's disease as a result of increased sex hormones from the adrenal gland (hirsutism). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Subjective Data: The Nursing Health History, p. 251.

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? A. Ulceration resembling a crater B. Exposure of subcutaneous tissue and muscle C. Broken with the presence of a blister D. Unbroken but red in color

Correct response: C. Broken with the presence of a blister Explanation: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, ABNORMAL FINDINGS 14-3 Primary Skin Lesions (continued), p. 274.

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? A. Stratum lucidum B. Epidermis C. Dermis D. Stratum corneum

Correct response: C. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, STRUCTURE AND FUNCTION, Skin, p. 248.

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take? A. Suggest the client shave their head. B. Notify the health care provider. C. Document findings. D. Inform the client to stop chemotherapy.

Correct response: C. Document findings. Explanation: Hair loss is a normal finding when a client is receiving chemotherapy. There is no need to notify the health care provider or for the client to stop chemotherapy. Even though the nurse may educate the client on alopecia and the use of hair wraps, wigs, or shaving of the head, this is not the best answer. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Subjective Data: The Nursing Health History, p. 251.

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? A. Nose and earlobes B. Around the mouth and lips C. Fingers and toes D. Chest and abdomen

Correct response: C. Fingers and toes Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 260.

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? A. Reynaud disease B. Neurofibromatosis C. Peripheral cyanosis D. Central cyanosis

Correct response: C. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 260.

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? A. Upper abdomen B. On the neck C. Under the breast D. Anterior chest

Correct response: C. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 262.

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

Correct response: C. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 263.

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions? A. fungal infection B. psoriasis C. hypoxia D. iron deficiency anemia

Correct response: C. hypoxia Explanation: Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, Collecting Objective Data: Physical Examination, p. 266.

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 A. ineffective individual coping related to changes in appearance. B. anxiety related to loss of outdoor activities and altered skin appearance. C. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. D. dry flaking skin and dull dry hair as a result of disease.

Correct response: C. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, STRUCTURE AND FUNCTION, p. 247.

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

Correct response: D. Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 260.

Which clinical manifestation should the nurse expect to find in a client with edema? A. Prominent blood vessels B. Decreased skin turgor C. Mottled skin tones D. Decreased skin mobility

Correct response: D. Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. 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. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Objective Data: Physical Examination, p. 264.

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 A. hyperthyroidism. B. hypoparathyroidism. C. infectious conditions. D. hypothyroidism.

Correct response: D. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Assessing Skin, Hair, and Nails, HEALTH ASSESSMENT, Collecting Subjective Data: The Nursing Health History, p. 251.