Chapter 9: The Integumentary System

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma? Solid, dark brown color Flat with silvery scales Diameter of 3 mm Asymmetric, irregular borders

Asymmetric, irregular borders

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

Carotene

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin A. B12. D. C.

D

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

Decreased skin mobility (assessed by gently pinching skin on sternum or under clavicle using two fingers and determine how easily skin can be pinched)

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? Decreased subcutaneous tissue Excessive collagen formation Inadequate circulation Continuous trauma

Excessive collagen formation

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? A normal finding Hypoxia Infection Vitamin C deficiency

Hypoxia

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Sweat glands Sebum production Subcutaneous tissue Squamous cells

Sebum production

What is the most important focus area for the integumentary system? Chemical exposure UV radiation exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure

A decrease in oxyhemoglobin will result in documentation of pallor. False True

true

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? Discrete Annular Linear Clustered

Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.

When documenting that a client has freckles, the appropriate term to use is macules vesicles patches bullae

macules

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

macules.

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? Chest and abdomen Nose and earlobes Fingers and toes Around the mouth and lips

Fingers and toes (changes in color around mouth are called circumoral; bluish tints to chest and abdomen is central cyanosis)

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 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? Cushing disease Diabetes mellitus Crohns disease Hypothyroidism

Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.

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? Central cyanosis Reynaud disease Peripheral cyanosis Neurofibromatosis

Peripheral cyanosis

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." Repeated sunburns in childhood may explain the presence of some of your moles. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." *RATIONALE*Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question

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? Newton scale Braden scale Norton scale Head-to-toe assessment

Braden scale

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 w/ presence of blister

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Move on to next body system Ask further questions Inspect the area Document the statement

Inspect the area 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.