Chapter 9: The Integumentary System

Which of the following terms is used to describe the arrangement of skin lesions? Annular Generalized Exposed Localized

Annular

When the nurse is inspecting a client's fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer? Subcutaneous Dermal Epidermal Sebaceous

Dermal Explanation: The dermis is connected to the epidermis by means of papillae that form the base for visible swirls or friction ridges, which provide the unique pattern of fingerprints.

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? Light palpation Deep palpation Moderate palpation Bimanual palpation

Light palpation

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? Cardiovascular failure Hepatic failure Respiratory failure Renal failure

Renal failure

According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) To reduce the risk of infecting healthcare personnel To reduce transient contamination of the hands To prevent the transmission of bacteria from nurses to clients To help maintain a sterile environment To reduce the number of bacteria in the health care environment

To reduce transient contamination of the hands To reduce the risk of infecting personnel To prevent the transmission of bacteria from nurses to patients

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action? Performing hand hygiene between examinations of each body part Discarding in the trash can the safety pin that was used to assess sensory perception Wearing a gown, gloves, and mask during the physical exam Wearing gloves to palpate the tongue and buccal membranes

Wearing gloves to palpate the tongue and buccal membranes

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 Around the mouth and lips Fingers and toes

fingers and toes 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

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is inspection. auscultation. percussion. palpation.

inspection.

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include "It is important to auscultate the bowel sounds heard with percussion." "Bowel motility is best heard before percussion." "It is easiest to hear bowel sounds using this technique." "Palpation will increase bowel motility and alter the sounds heard on auscultation." "It is important to auscultate the bowel sounds heard with percussion." "Bowel motility is best heard before percussion." "It is easiest to hear bowel sounds using this technique." "Palpation will increase bowel motility and alter the sounds heard on auscultation."

"Palpation will increase bowel motility and alter the sounds heard on auscultation."

For which of the following clients should the nurse choose to perform a focused examination? A woman who has an especially complex medical history A woman who is new to the community and has presented to the clinic to establish care A man who has presented with an acute onset of chest pain A man whose mobility is compromised by disability

A man who has presented with an acute onset of chest pain

A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client? Warm comfortable room Firm examination bed or table Quite area free of disturbance Adequate lighting SUBMIT ANSWER

Adequate lighting- Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.

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 "ABCD" characteristic of malignant melanoma? Diameter less than 6mm Borders well demarcated Asymmetrical shape Color is uniform

Asymmetrical shape 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 to1/4 inch (3-4mm), and E for elevated.

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? Bacteria Parasites Fungus Blood

Blood

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? Stratum lucidum Dermis Epidermis Stratum corneum

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.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Type Arrangement Distribution Color

Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.

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 Suggest that the client use antiperspirant products Monitor the client for additional findings of cystic fibrosis Assess the client for changes in sensation due to vascular problems

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. (less)Reference:Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 241.

The nurse is preparing to examine a client's skin. What would the nurse do next? Wear gloves when preparing to inspect the skin and nails. Have the client remove clothing from the upper body. Ensure that the room is hot to prevent chilling. Expose only the body part that is being examined.

Expose only the body part that is being examined.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? Heart sounds Femoral pulses Bowel sounds Breath sounds

Heart sounds

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this? Sphygmomanometer Ophthalmoscope Stethoscope Otoscope

Otoscope

Which of the following is a component of the general survey? Patient's breath sounds Patient's blood pressure Patient's state of hygiene Patient's oral temperature

Patient's state of hygiene

It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement? Client's height Mid-arm circumference Skin lesion size Pupillary size

Skin lesion size

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 asthma The client has melanoma The client has COPD The client has chronic hypoxia

The client has chronic hypoxia

Which describes the nurse using the technique of auscultation? The nurse notes a small nodule in the breast. The nurse notes dullness over the liver. The nurse detects gurgling throughout the abdomen. The nurse detects foul odor of the urine.

The nurse detects gurgling throughout the abdomen

Which describes the nurse using the technique of percussion? The nurse detects rustling over the individual's thorax. The nurse notes resonance over the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects crepitus over the individual's thorax.

The nurse notes resonance over the individual's thorax.

Which action by a nurse demonstrates the correct application of the principles of standard precautions? Wearing a gown, gloves, and mask for the physical exam Using an antiseptic hand scrub to cleanse visibly soiled hands. Wearing gloves when palpating the tongue, lips, & gums Change gloves after each body area is examined

Wearing gloves when palpating the tongue, lips, & gums

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact? reflex hammer scoliometer penlight pulse oximeter

reflex hammer