Health Assessment Chapter 14

he student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

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 A macule is a flat, non-palpable 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 it 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 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 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 nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

Alcoholism A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinsons disease is associated with stiff, rigid movements. Marfan;s syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing;s syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump).

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?

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

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.

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to the touch

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The patient may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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 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.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

ashen. Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

sclera.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

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.

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 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.

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 chronic hypoxia Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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. 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.

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

Dermis 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.

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 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 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 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.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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?

Under the breast 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.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast. The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale Identifying risk for skin breakdown is especially important in hospitalized or inactive patients. Many health care facilities use the Braden Scale to assess risk in patients, with interventions based on the total score.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

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 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.

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 = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution

Which of the following is an important function of the skin?

Synthesis of vitamin D A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis. 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.

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?

high his 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.

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.

Keep the room door closed Wear gloves when palpating lesions Use sunlight, if possible, to inspect the skin Have the client remove his toupee To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on an examination gown. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. The client may remain in a sitting position for most of the examination. If available, sunlight is best for inspecting the skin. Wear gloves when palpating any lesions because you may be exposed to drainage. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.

A decrease in oxyhemoglobin will result in documentation of pallor.

True

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.

Activity Moisture Nutrition The Braden Scale is a simple effective tool that evaluates levels of risk for ulcer development in the patient. With its high reliability, predictive validity, and ease of use, the Braden Scale can be used to assess patients as often as every shift if needed. Six factors are rated using a matrix scoring system: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client?

Age The risk for melanoma is increased in people older than 50 years; this client is 35 years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Skin that feels boggy on palpation

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

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

fainting 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.