Health assessment test 3

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

"Do you take steroid medications on a regular basis?"

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

"It takes about 6 months to totally replace a fingernail."

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch"

A mother brings her 5-year-old son who is of African descent to the clinic. The mother is concerned about recent changes in her child's hair color from black to a copper-red. What is the best response by the nurse?

"This could be a sign of malnutrition."

Tick bite

"target" lesion that appears at site of the bite- requires prompt medical evaluation

Jaundice

(yellow discoloration of the skin, sclera, or buccal mucosa; shown)-Liver disease

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

Wheal

Primary skin lesion Raised Flesh-colored or red edematous papules or plaques Vary in size and shape Ex: urticaria (hives)

Skin tags

Skin tags are common in pregnancy and in aging skin.

Vesicle

Fluid-filled, less than 1 cm diameter Ex: Herpes simplex, chicken pox (shown)

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

Grouped

Lesions are clustered together

Raynaud phenomenon

Pallor of fingers and toes in response to cold

Bulla

-Ex: Partial-thickness burns, bullous impetigo > 1cm in diameter

Unstagable ulcer

-Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown), eschar (tan, brown, or black), or both. Until enough slough or eschar is removed to expose the base of the wound, true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

Malignant melanoma

-Malignant melanoma is identified by the ABCDEs of skin cancer detection. Metastasizes quickly.

Lipoma

-tumors composed of fat cells that are benign, some varieties are painful. Lipomas range in size

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

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

Annular

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

Avoiding sun exposure

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

Can be caused by an underlying systemic illness

Hematoma

Collection of blood under the skin usually results from blunt-force trauma. Hematomas are palpable lesions, and coloration mimics that of ecchymosis

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days

Spoon nails (koilonychia)

Transverse and longitudinal concavity of the nail, giving the appearance of a spoon. May be normal in infants (usually resolves in few months). Other causes include trauma, iron-deficiency anemia,etc.

Avulsion

Trauma forces the skin to separate from underlying structures, leaving an open ragged wound

Local redness of the skin warns of impending necrosis.

True

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 reports that he might have shingles. Which type of lesion would the nurse most likely assess?

Vesicle

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

Vesicle

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

Wood's light

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.

a cancerous skin lesion located on the back, presence of a systemic disease like measles, a rash triggered by taking the medication ibuprofen, a reddened area on the heel that indicates a potential risk for pressure ulcer formation

Linea nigra

a dark line appearing on the abdomen and extending from the pubis toward the umbilicus; may appear around second trimester and caused by hormones

Scar

after damage to skin; secondary lesion

Tinea pedis

athlete's foot

Cellulitis

bacterial infection of deep skin tissues, often preceded by a minor wound to the area allowing bacteria to invade the tissue. Cellulitis can occur anywhere and is characterized by swelling, redness, warmth, and tenderness or pain. Look for unilateral edema, warmth and redness

Lentigo

benign, pigmented macules found generally on sun-exposed skin

Sanguineous

bloody

Squamous cell

can become invasive if not treated

Candida

fungus commonly found in skinfolds or generally warm and moist areas. Commonly affected sites are the axillae and groin. Wash and dry between skin folds in clinical! Need antifungal to treat. Powder and lotion won't cure.

Alopecia

hair loss

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 nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?

hypoxia

Localized

in a specific area

A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?

increased body and facial hair

Paronychia

inflammation of tissue surrounding nail

Tinea cruris

jock itch

The nails, located on the distal phalanges of the fingers and toes, are composed of

keratinized epidermal cells.

Excoriation

lesion resulting from scratching or excessive rubbing; secondary lesion

Linear

lesions form a straight line

Fissure

linear break in skin surface; secondary lesion

Zosteriform

linear shape of skin lesion along a nerve route; seen with shingles because the outbreak is along a dermatome

Erosion

loss of epidermal layer: secondary lesion

Vitiligo

loss of pigment in areas of the skin

ulcer

loss of skin surface, extending into dermis, subcutaneous, fascia, muscle, bone, or all. TURN EVERY 1-2 HOURS. REPOSITION EVEN IF IN WHEELCHAIR. secondary lesion

Basal cell

not usually invasive

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 mm, asymmetry

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies

diffuse

scattered

Squamous cell carcinoma

second most frequently found skin cancer is related to sun exposure

discrete

separate, distinct, unconnected lesions

Petechiae

small reddish to purple macules or papules can develop anywhere on body in response to physical trauma

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 a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage II

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

Striae

stretch marks

Connecting the skin to underlying structures is/are the

subcutaneous tissue

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?

"Do you feel anxious at times?"

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?

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?

"How has it changed?"

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

Pitted nails

-Lesions from psoriasis; arise from nail matrix that causes pitting on the nail plate as it grows

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

Allow early identification of neurologic deficits

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

Are you allergic to foods, medications, or other substances?

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

Stage IV pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue so these ulcers may be shallow. Stage IV ulcers can extend into muscle, supporting structures (e.g., fascia, tendon, joint capsule), or both, making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

IgE

Immunoglobulin E are antibodies produced by the immune system. Often associated with allergic responses

Lice (pediculosis)

Infestations on the head (pediculosis capitis), body (pediculosis corporis), or genitals. Secondary lesions often result from scratching.

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?

It is likely to be related to her lupus.

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

Osteomyelitis

Neuropathic ulcer

Peripheral neuropathy in diabetes

Purpura

Purplish macules or papules result from bleeding under skin secondary to inadequate clotting mechanisms

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

Clubbing

Results from chronic hypoxia to distal fingers, such as in emphysema or congestive heart failure

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

Laceration

Tears in the skin can be superficial or deep, short or long, and frequently require suturing to heal correctly

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

The client is consistently incontinent of urine

A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following?

Thin

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

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

Touch with the palmar surface of the three middle fingers

Gram Stain

a staining technique for preliminary identification of bacteria

Milia

common on newborns. Teach parents not to squeeze

Keloid

excessive scar formation-more common in African American patients; secondary lesion

Lanugo

fine hair that lessens closer to term (helps vernix stick to skin)

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

Generalized

over large areas of body

Squamous cell carcinoma is associated with

overall amount of sun exposure

Vernix

protects skin from amniotic fluid

Purulent

pus

Malignant melanoma

quick to metastasize

Lichinification

thickened, rough skin caused from excessive scratching; secondary lesion

Atrophy/striae

thinning of skin from loss of skin structures-stretch marks; secondary lesion

Patch test

used for allergy testing

Short, pale, and fine hair that is present over much of the body is termed

vellus

Biopsy

we see this used if skin cancer is suspected

Aktinic keratosis

-AKA solar keratosis, usually are found on sun-exposed skin and are thought to result from UV damage-rough or scaly surface

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

1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

A neuropathic ulcer can develop without feeling it.

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following?

Acute illness

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

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

Alopecia areata

Mongolian Spot

Any of a number of dark-bluish or mulberry-colored spots observed in newborns, that enlarge for a short time after birth and then gradually recede during childhood. Common in black, native American, and Asian children. Sometimes mistaken for bruising and child abuse

Half and half nails

Color changes associated with chronic renal failure; proximal portion of nail is white, distal portion is pink or brown

A nurse observes a bluish discoloration in a client's toes. What is the first action of the nurse?

Complete a comprehensive assessment

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

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take?

Document findings

The nurse is performing a focused assessment on a 45-year-old client of African descent. The nurse observes the following: nail beds have pigmented streaks, 160-degree angle between the nail base and the skin. What action should the nurse take?

Document the findings 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

Hirsutism

Excessive androgenic hormones female can cause masculinization changes including hair in male distribution patterns (beard, chest, back, upper thighs

Stage III pressure Ulcer

Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

When assessing your new client, you note that he has no hair on his legs. What might this indicate about the client?

He has peripheral artery disease

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

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

Keloid formation at the site of an old incision

Excoriation

Lesion resulting from scratching or excessive rubbing of skin Ex: Cat scratches

Annular

Lesions are arranged in a single ring or circle

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

Melasma generally resolves postpartum

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply

Modify nursing interventions, Document the findings, Notify the physician

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Oral mucosa

For which client condition would the nurse most likely expect a capillary refill time longer than 2 seconds?

Peripheral vascular disease

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Petechiae

Ecchymosis

Physical trauma to the skin damages capillaries and allows blood to seep into surrounding tissues. As blood is gradually resorbed, color changes and may be purple, blue, green, yellow, or brown

Papule

Primary skin lesion Raised Defined Any color <1 cm diameter Ex: wart, insect bite

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

Beau line

Results from slowed or halted nail growth in response to illness, physical trauma, or poisoning

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

Spooning

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

There is a non-blanching reddened area on the client's coccyx region

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

areola of the breast.

Serous

clear and watery

Crust

dried excretions; secondary lesion

Wallace Rule of Nines

estimates percentage of total body surface area burned in adults. Different areas are sectioned into numerical values related to the figure nine (9). Note that the anterior and posterior head equate to 9% each

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

folliculitis

The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

papule

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a

papule

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

Tinea corporis

ringworm

Tinea unguium

ringworm of the nails

Tinea capitis

ringworm of the scalp

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

Stage I pressure ulcer

-Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in people with dark skin

Karposi sarcoma

-This opportunistic skin infection is consequence of impaired immune status, such as associated with AIDS. Lesions generally occur on the nose, penis, and extremities, although with advanced HIV, distribution may be more generalized. Improved immune status may cause resolution.

Basal cell carcinoma

-appears shiny w/ rolled pearly border; typically has telangiectases (small spider veins) on its surface. This skin cancer grows slowly and rarely metastasizes

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

15

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?

19 to 23

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 notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash?

Allergic reaction

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

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

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process?

Diabetes mellitus

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?

Discrete

Cyst

Distinct and walled-off, containing fluid or semisolid material, varies in size Ex: Epidermal cyst (shown), cystic acne

Stage II pressure ulcer

Partial-thickness loss of dermis presenting as a shallow open ulcer with a reddish pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next?

Perform a random blood sugar test

A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?

Pityriasis rosea

Macule

Primary skin lesion Flat Circumscribed Discolored <1cm diameter Ex: Freckles (normal finding), stork bite

Patch

Primary skin lesion Flat Circumscribed Discolored >1 cm in diameter Ex: vitiligo, melasma, tinea versicolo

Nodule

Primary skin lesion Palpable <1 cm diameter Often with some depth Ex: Basal cell carcinoma

pustule

Primary skin lesion Purulent Raised of any size Ex: pustular acne (pus)

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 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

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

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage II

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

The client had a recent infestation

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position

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.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness

Eosinophils

a type of white blood cell that is often elevated with allergic diseases and infections, so commonly elevated with skin issues

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease

Melasma

aka mask of pregnancy. From increased hormones causing increased pigmentation.

Culture and sensitivity

always get the exudate for a culture!!

confluent

another word used when lesions become merged

A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings?

ask the client if they experience periods of excessive sweating

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 spot

caused by aging of the skin in older adults

Scale

common with psoriasis; secondary lesion

Serosanguineous

contains serous and sanguineous, so often a pink color

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

dermis

The nurse is assessing a client exhibiting round, red and purple macules that are approximately 1 to 2 mm in size. The nurse should document which type of vascular skin lesion?

petechiae

Psoriasis

pink plaques with silvery scales