Chapter 14: Assessing Skin, Hair, and Nails PrepU

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?

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 golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

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

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.

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?

Dry and rough Explanation: A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

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 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.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

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.

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

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.

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?

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.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

Asymmetrical shape Explanation: Malignant melanomas are evaluated according to the mnemonic ABCDE: 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.

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client. Explanation: Friction and shear forces are risk factors for developing pressure ulcers. The nurse should ask for help and use a draw sheet to avoid shearing forces. Pulling the client up in bed and allowing the client to slide in bed create friction and shear forces. Pushing the client also creates shearing forces.

A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the patient questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

Destruction of hair follicles located in the dermis layer Explanation: Damage to hair follicles located in the dermis layer of the skin would result in the body's inability to regrow hair on burn damaged areas. The remaining options suggest correct information but none are associated with the regrowth of hair after a burn.

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 Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral 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?

Macule Explanation: A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

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 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 problems 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 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 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.

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?

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.

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis. Explanation: Cyanosis 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.

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

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.

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

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.