Health Assessment Prep U Health

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

dermis.

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

fainting

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures.

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.

A client with a zosteriform rash has a rash that

is distributed along a dermatome

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

notched border diameter great than 6 cm asymmetry

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa.

Which situations should the nurse identify as being risk factors of the development of pressure sores?

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for:

symptoms of stress.

To assess an adult client's skin turgor, the nurse should

use two fingers to pinch the skin under the clavicle.

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.

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

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

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

Carotene

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

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

Dermis

A client 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 client 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

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

Distribution

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

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

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

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking

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

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

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

Moisture Activity Nutrition

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?

Peripheral cyanosis

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

Pustular acne

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

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial

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

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

A decrease in oxyhemoglobin will result in documentation of pallor.

True

Local redness of the skin warns of impending necrosis.

True

What is the most important focus area for the integumentary system?

UV radiation exposure

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

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

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal

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

Wood's light

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

[Feet with tattoos] Burning when having an MRI

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.

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

areola of the breast.

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

ashen.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue

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.

Which of the following terms is used to describe the arrangement of skin lesions?

Annular

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease?

Asymmetrical Change in size Itching Bleeding of a mole

Which clinical manifestation should the nurse expect to find in a client with edema?

Decreased skin mobility

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?

Dermis

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

Macules

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?

Seborrheic keratosis

The nurse is admitting a 79-year-old man for outpatient surgery. The client 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 client may have been abused.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia.

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

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

assessing the client's hard palate with a bright light

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

at the bottom of the picture where the arteries, vein, and fat.

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

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

Assists in friction protection

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?

Broken with the presence of a blister

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

Consider admitting the client to the hospital.

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

Existence of systemic diseases that have skin manifestations

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.

Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric

The nurse expects what change in a client's hair as a result of aging?

Sebaceous glands will secrete less causing hair to be drier.

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails