EAQ CH 41 Structure, Function, and Disorders of the Integument

A nurse observes a diagnosis of furuncles. How should the nurse interpret this finding?

Inflammation of the hair follicle

A nurse is asked about a typical trigger for keloid formation. How should the nurse respond?

Surgery can be a typical trigger.

Which specific part of the nervous system regulates vasoconstriction and vasodilation through α-adrenergic receptors in the client's skin?

Sympathetic nervous system

Capillary dilation can produce which primary skin lesion in a client?

Telangiectasia Telangiectasia is described as fine, irregular red lines produced by capillary dilation (such as those seen with spider veins in legs).

Which manifestation may the nurse observe in a client with discoid lupus erythematosus (DLE)?

Telangiectasias

A client has frostbite. Which assessment findings are typical of this condition?

The area is yellowish with a waxy texture.

Which information from the client indicates teaching by the nurse was successful about the primary function of the skin?

The primary function is protection.

Which statement by the client indicates teaching was successful for second-degree, superficial partial-thickness burns?

These burns usually heal in 3 to 4 weeks.

A client reports persistent pain along a rib on the anterior and posterior surface of the chest. There were numerous vesicles noted in a stripe fashion, but these abated about 9 weeks ago. The nurse is caring for which client?

A client with postherpetic neuralgia

A client has a condition that is caused by a virus. The nurse is caring for which client?

A client with warts

A nurse is asked what a melanocyte is. How should the nurse respond?

A pigment-producing cell in the skin

Which clients have conditions that are caused by a virus? Select all that apply.

A teenager with warts A young person with herpes zoster

A nurse is caring for a client with hirsutism. Which client is receiving care from the nurse?

A woman with excess hair

A client has paronychia. Which action will the nurse question?

Administering an oral antifungal to the client

What is the priority goal when planning care for a client with burns?

Wound débridement

In an aging client, what occurs due to the loss of elastin?

Wrinkles

Which information from the staff indicates teaching by the nurse was successful about the structure that supplies blood to the skin?

Papillary plexus

A client presents to the emergency department with oral lesions, skin blistering on the face and scalp. The blisters rupture easily and are distressful to the client. Which most common form of pemphigus will the nurse most likely observe written in the chart?

Pemphigus vulgaris

Which term should the nurse use that is representative of the processes involved in psoriasis?

Proliferative

A nurse is caring for a client with pruritus. Which goal will be the priority?

Reduction of itching

What occurs as the lymphatic vessels in the client's skin drain into larger subcutaneous trunks? Select all that apply.

Removal of cells Removal of proteins Removal of immunologic mediators

The nurse understands that a decrease in blood flow and a slower rate of basal cell turnover places the geriatric client at risk for which occurrence?

Decreased wound healing

What assessment findings are typical for a client with scleroderma? Select all that apply.

Dilation of capillaries Tightening of skin over the fingers and toes Calcium deposits in the subcutaneous tissue

How should the nurse describe the rash associated with pityriasis rosea?

Drooping pine tree

Which layer of a client's skin contains stratum basale and spinosum layers?

Epidermis

What is the most common lesion color the nurse will observe upon assessment of a client with acne rosacea?

Erythematous

A nurse is teaching a health and wellness class about risk factors for skin cancer. Which information indicates teaching was successful?

Exposure to ultraviolet radiation is a high-risk factor.

A nurse is using the "rule of nines." What is the nurse assessing in a client?

Extent of total body surface area (TBSA) burned

A client with skin dysfunction develops a pressure ulcer, causing an inflammatory response. In determining an inflammatory response, the nurse assesses for which signs? Select all that apply.

Fever Hyperemia Increased white blood cell count

A client has an infection from Candida albicans. Which type of microorganism caused this infection?

Fungus

Which information from the client indicates teaching by the nurse was successful about the potential causes of psoriasis? Select all that apply.

Genetic factors Strong family history Inflammatory process

In which area of the body would the nurse expect to see the rash associated with lichen planus?

Genitalia

A client has a potential for skin dysfunction. Which area should the nurse specifically assess for early detection of pressure ulcer formation in a client?

Greater trochanter Pressure ulcers usually develop over bony prominences, such as the sacrum, heels, ischia, and greater trochanters. The hands, inner thighs, or cervical and thoracic regions of the vertebrae usually would not be sites of pressure ulcers.

A nurse is teaching the staff about herpes simplex virus I (HSV I) infection. Which information should the nurse include? Select all that apply.

HSV I begins with a burning or tingling sensation. HSV I reactivates with stress, sun exposure, or fever. HSV I develops lifelong latency in the dorsal root ganglion.

During report, the nurse hears that the client had initial symptoms of pain and paresthesia followed by vesicular eruptions along the distribution of a spinal nerve (dermatome). The nurse will be caring for a client with which condition?

Herpes zoster

A client with severe psoriasis should be screened for which comorbid conditions? Select all that apply.

Hypertension Insulin resistance Rheumatoid arthritis Inflammatory bowel disease

Which physiologic processes make a client predisposed to burn shock? Select all that apply.

Hypovolemia Increased capillary permeability

A client has freckles. The nurse should use which medical term to describe this type of skin lesion?

Macule

Upon assessment of the client, the nurse finds a nonpalpable spot that is not elevated or depressed. Which term should the nurse use to document this finding?

Macule

What is a treatment goal for a client diagnosed with psoriasis?

Maintaining skin moisture

Which microorganism is associated with seborrheic dermatitis of the client's scalp and eyebrows?

Malassezia

Which technical term should a nurse use to describe the assessment finding of a small blister filled with serous fluid?

Vesicle

Which major characteristic will help the nurse determine the difference between a vesicle and a wheal?

Vesicles contain fluid, but wheals are solid.

Which type of medication would the nurse expect to see prescribed for the client diagnosed with lichen planus?

An antihistamine

Which client has the deadliest form of skin cancer?

An older male client with malignant melanoma

A client has a pressure ulcer. Which action will the nurse implement?

Apply a hydrogel dressing

A nurse is teaching the client about the layers of the skin. Which area (see diagram) should the nurse choose to illustrate the epidermis?

Area 1

Which structure in the dermis facilitates the regulation of a client's body temperature?

Arteriovenous anastomoses

Which interventions would be appropriate for a client diagnosed with a stasis ulcer? Select all that apply.

Avoid long periods of standing Moist dressings for chronic lesions Avoid tight clothes around the legs Treatment of infection with appropriate antibiotic

A nurse is performing skin screenings at a health fair. Which form of skin cancer should the nurse screen for because it is the most common?

Basal cell carcinoma

A client has pemphigus. Which type of skin lesion will the nurse typically find upon assessment?

Blisters

A client has Kaposi sarcoma. Upon assessment by the nurse, which finding is typical of the lesion?

Brownish purple skin lesion

Which assessment finding/characteristic is typical in a client with discoid (cutaneous) lupus erythematosus (DLE)?

Butterfly lesion pattern over nose and cheeks The face is the most common site of lesion involvement, with a butterfly pattern of distribution found over the nose and cheeks. It typically begins in the late thirties or early forties although it can occur at any age. Erythema multiforme produces a "bull's eye" or "target" lesion on the skin.

A client has folliculitis. Which action should the nurse take?

Clean the area with soap and water Cleaning with soap and water is an effective treatment for folliculitis. Prolonged skin moisture would aggravate the condition; in fact, prolonged skin moisture can cause folliculitis.

Which determinations are necessary when the nurse is assessing for clinical manifestations of skin dysfunction? Select all that apply.

Completing a health history Observing the appearance of the skin Identifying morphologic structure of the skin

Which instructions should be included in the teaching plan for a client diagnosed with acne rosacea?

Consume hot drinks cautiously

Which term should the nurse use to describe a client's fingernail bed?

Hyponychium

Which assessment findings are typical of clients with herpes zoster?

Dermatomal distribution of lesions and pain

Which glands are important in cooling a client's body through evaporation?

Eccrine glands

A client is having problems with thermoregulation. Which structures that help with thermoregulation are located in the greatest numbers on the palms of the hands and soles of the feet?

Eccrine sweat gland

What are the most common inflammatory skin disorders in clients? Select all that apply.

Eczema Dermatitis

A client has stasis dermatitis. Which intervention will the nurse implement?

Elevate the legs as often as possible

A nurse is teaching a client about herpes simplex virus 1 (HSV-1). Which information should the nurse include in the teaching session? Select all that apply.

Fever may cause reoccurrence. It is transmitted by infected saliva Lesions of HSV-1 are typically found near the mouth. It appears as a rash or clusters of inflamed and painful sores.

Upon assessment of a client, a nurse notes petechiae. What did the nurse observe? Select all that apply.

Flat lesion Change in color of skin Lesion less than 1 cm in diameter

What occurs if there is continuous unrelieved pressure on the client's skin? Select all that apply.

Formation of microthrombi that block the blood flow Lack of blood flow causing anoxic necrosis of surrounding tissues Endothelial cells lining the capillaries becoming disrupted with platelet aggregation

A client has cutaneous vasculitis. What is the first step of treatment?

Identifying and removing the antigen

A client has latex allergy and develops allergic contact dermatitis. Upon reviewing the laboratory reports, which immunoglobulin antibody level would be elevated?

IgE

With aging, what occurrences are due to the loss of epidermal rete pegs? Select all that apply.

Increased likelihood of tearing of the skin Weakening of the connection to the dermis

A client has psoriasis. Which physiologic processes should the nurse remember about psoriasis when planning care? Select all that apply.

Infiltration of neurtrophils Altered kerotinocyte differentiation Results in the hyperproliferation of cells Causes an expanded dermal vasculature

Upon assessment, the nurse finds thick, well-demarcated, silvery, scaly erythematous plaques located in the axillae. What type of psoriasis did the nurse observe?

Inverse

Which information should the nurse include when teaching the staff about scleroderma? Select all that apply.

It is an autoimmune disease. There are massive deposits of collagen with fibrosis.

Which clinical manifestations will the nurse observe upon assessment of a client with allergic contact dermatitis? Select all that apply.

Itching Swelling Erythema Vesicular lesions

Which term should the nurse use to describe a scar that extends beyond the border of traumatized skin?

Keloid

Which information by the nurse indicates an understanding of geriatric considerations for the aging client?

Langerhan cells decrease in number

Which statement by the nurse indicates an understanding of Merkel cells in a client's skin?

Merkel cells are associated with sensory nerve endings.

A client has lipoma. The client has which type of skin lesion?

Nodule

Which term should the nurse use to describe a large, palpable bump located on the client's nose?

Nodule

A client has a major burn injury. During the immediate, acute phase of the burn, which goal is priority?

Prevent burn shock

A clinic nurse is treating a client that has the most common type of psoriasis. The nurse is caring for which client?

One with plaque psoriasis

A nurse is caring for clients with viral infections. The nurse is caring for which clients? Select all that apply.

One with varicella One with herpes zoster One with herpes simplex

The nurse is assessing the client's skin and observes an elevated, firm, and rough lesion with a flat top surface more than 1 cm in diameter. The nurse should use which term to chart this finding?

Plaque

A client has multiple areas of folliculitis in the scalp. Which factor may contribute to the development of this disorder?

Poor hygiene

A nurse wants to prevent pressure ulcers in a client. Which actions should the nurse take? Select all that apply.

Promote movement Eliminate excess moisture Provide nutrition, including fluids

A nurse is teaching the staff about papulosquamous disorder. Which examples should the nurse include in the teaching session? Select all that apply.

Psoriasis Lichen planus Pityriasis rosea

Which term should the nurse use to describe an elevated lesion containing purulent material located on the client's abdomen?

Pustule

Which assessment finding that the nurse observes in a client is characteristic of candidiasis?

Red, swollen, painful tongue

A client has tinea capitis. Which area should the nurse assess first?

Scalp

A newborn has cradle cap. Which type of dermatitis is the newborn experiencing?

Seborrheic

Upon assessment, the nurse finds chronic, scaly, white or yellowish inflammatory plaques with mild pruritus on the eyelids, chest, and back. Which type of dermatitis will the nurse observe written on the chart?

Seborrheic

A nurse is assessing external factors for the development of pressure ulcers in a client. Which factors should the nurse include? Select all that apply.

Sedation Contractures Coarse bed sheets Lack of education regarding pressure ulcer care

A client has plaque psoriasis. Which finding will the nurse observe during the assessment?

Silvery scale on the skin

A nurse is asked what the largest organ of the body is called. How should the nurse respond?

Skin

Which layer of a client's epidermis contains cells that undergo mitosis?

Stratum basale

A nurse is teaching a client about the function of sebaceous glands. Which information indicates teaching was successful regarding the function of sebaceous glands?

These glands' function prevents drying of the skin and hair.

Upon assessment, a nurse finds hives on a client. Which technical term should the nurse use to describe this assessment finding?

Urticaria

A nurse is helping to plan a community prevention program for skin cancer. Which risk factor should the nurse recommend including in the program?

Use of tanning beds

During rounds with the primary care provider, which finding would cause the nurse to have the primary care provider further evaluate a nevus mole?

Variations in color within the nevus

A nurse is teaching the staff about the layers of the epidermis. How should the nurse present the layers, in order, beginning with the outermost layer?

1.Stratum corneum 2.Stratum granulosum 3.Stratum spinosum 4.Stratum basale

A client has shingles. What will the nurse typically find in the history?

Childhood incidence of chickenpox

For the geriatric client, the nurse would observe for increased risk of injury and infection due to the reduction of which layer of the epidermis?

Stratum corneum

A nurse is teaching an adult community group about skin cancer. Which information should the nurse include?

Sun protection should begin in childhood.

The nurse is caring for a client with a burn that has caused the affected skin color to vary from red to pale ivory with a moist, blistered surface. There are intact tactile and pain sensors resulting in severe pain. These descriptions are associated with which burn wound depth?

Superficial partial thickness