Integumentary Assessment Case Study

The nurse begins her assessment of the integumentary system. Place the items in the order that the nurse should perform the techniques for physical examination of the integumentary system.

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

The nurse prepares to administer diphenhydramine 50 mg orally. The tablet is supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value only. If rounding is necessary, round to the tenth.)

2 D/H 50/25 = 2

The nurse teaches the client about diphenhydramine. Which information should the nurse include? (Select all that apply. One, some, or all options may be correct.) A. Diphenhydramine blocks the effect of the histamine response to reduce itching. B. Diphenhydramine products contain aspirin, so observe for signs of bleeding. C. This medication may cause drowsiness. D. Blurred vision or loss of balance are potentially serious side effects of this medication. E. This medication may cause an increase in secretions and moisten mucous membranes.

A, B, C Diphenhydramine is a H1 receptor antagonist and may be helpful to reduce itching associated with hives. All diphenhydramine products are aspirin free and bleeding is not a side effect. Although considered a minor side effect, diphenhydramine may cause drowsiness.

The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask? A. Have you experienced nausea or vomiting recently? B. How much water are you drinking per day? C. Have you experienced diarrhea recently? D. Are you feeling dizzy? E. Is your mouth dry?

A, B, C Vomiting can cause loss of fluid resulting in fluid volume deficit. Inadaquate intake of fluids especially water may result in fluid volume deficit. Diarrhea can cause loss of fluid resulting in fluid volume deficit.

The nurse questions the client about anaphylaxis. What client cues would indicate the the presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be correct.) A. Drooling B. Shortness of breath C. Diaphoresis D. Flushed or pale skin E. Tremors or Seizures

A, B, D The client denies difficulty swallowing, shortness of breath, nausea, or dizziness. No centralized pallor or flushing is noted. The nurse determines that the client is not having a anaphylactic reaction. The nurse will continue to monitor the client for changes in condition. The nurse completes the client interview. The client denies history of skin conditions, rashes, new medications or changes in toiletry or laundry items. The nurse completes the initial client interview and determines the client is in need of diphenhydramine to reduce the effects of the itching. The chart notes parental consent of prn Diphenhydramine.

While assessing the client's nails, it is most important for the nurse to follow-up on which assessment finding? A. Brittle nail surface. B. Ragged cuticles. C. Firm nail base. D. Traumatized nail folds

A. Brittle nail surface. Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client's nutritional status.

The nurse observes that there are numerous blackheads around client's chin and nose. What action should the nurse take in response to this finding? A. Note any pustules or nodules. B. Ask about a history of eczema. C. Measure for pitting edema. D. Palpate the areas for tenderness.

A. Note any pustules or nodules. Blackheads are a form of acne, common in the adolescent when sebaceous gland activity increases. The nurse should look for signs of severe acne which may be manifested as pustules or nodules on other parts of the client's body (such as the back or chest).

While observing the mole and cherry angioma on the client's abdomen earlier, the nurse also observed several areas of apparent skin injury on the client's lower abdomen. Because the nurse feels a trusting relationship has now been established, the nurse believes that the client may allow further assessment of the injured areas. The nurse asks the client about observing the abdomen again. The client agrees. The nurse observes several bruises of various colors across the client's lower abdomen. How should the nurse interpret this assessment finding? A. Repeated injury over a period of time. B. Recent injury with different sized objects. C. Skin exposure to hot and cold objects. D. The client is the victim of abuse.

A. Repeated injury over a period of time. New bruises are generally red in color and change color over time. Bruises typically progress from purple-blue to blue-green to green-brown and finally to a brownish-yellow color before disappearing.

What additional observation is important in assessing the mole? A. The border of the mole is smooth. B. The mole is surrounded by freckles. C. There is no inflammation around the mole. D. The mole does not blanche when compressed.

A. The border of the mole is smooth. Border regularity is an important finding because border irregularity may be a cancer danger sign.

The nurse expresses concern regarding the client's bruise. What action should the nurse take to initiate the abuse assessment? A. Determine if the client is sexually active. B. Ask the client if someone else caused the injuries. C. Encourage the client to describe the family structure. D. Advise the client of the right to legal counsel during the interview.

B. Ask the client if someone else caused the injuries. It is appropriate to first ask a direct question to elicit information about possible abuse. If the client is reluctant to respond to a direct question about possible abuse, the nurse may then choose to use an indirect approach to encourage further verbalization.

The nurse completes the assessment of the client's skin lesions. The nurse begins to examine the client's fingernails. The nurse observes that the nail surface is slightly curved and the angle of the nail base is 160 degrees. What action should the nurse take in response to this finding? A. Ask the client about any current or past use of cigarettes. B. Continue the assessment, noting the color of the nail surface. C. Use a pulse oximeter to measure the oxygen saturation. D. Assess for the presence of Beau's lines.

B. Continue the assessment, noting the color of the nail surface. A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface.

The client states, "My scalp itches sometimes." What action should the nurse take first? A. Instruct the client about dandruff treatments. B. Observe the client's hair shafts and scalp. C. Remind the client not to share hairbrushes. D. Question the client regarding frequency of shampooing hair.

B. Observe the client's hair shafts and scalp. Loose white flecks may indicate dandruff. Itching may also be the result of head lice, the nurse should observe the scalp and hair shafts for the presence of nits, which adhere to the hair shaft.

Before reporting the information obtained about the physical abuse that the experienced, the nurse documents the findings. How should the nurse document the information obtained when charting the client's abuse assessment? A. Clarify that the information was obtained after the client took diphenhydramine. B. Quote the client's responses to the questions as verbatim as possible. C. Summarize the abusive events without directly quoting the client. D. Refrain from including information that might identify the alleged abuser.

B. Quote the client's responses to the questions as verbatim as possible. Documentation should be as verbatim as possible to provide the most detailed, accurate information.

What health promotion question is most important for the nurse to ask the client? A. "Do you tend to bite or chew your nails?" B. "What do you use to cleanse your skin?" C. "How often do you use a tanning booth?" D. "Do you use a hair coloring product?"

C. "How often do you use a tanning booth?" Excessive use of a tanning booth increases the risk for skin cancer. Therefore, this is the most important question for the nurse to ask the client. The client states that she goes to a tanning booth once or twice a month.

The nurse assesses that the client's skin turgor is slightly inelastic. The nurse suspects that the client is fluid volume deficient. What cues support the nurse's assessment regarding the client's fluid status? A. Areas of skin bruising. B. Rapid facial flushing. C. Dry mucus membranes. D. Shiny appearance of the forehead.

C. Dry mucus membranes. Dry or cracked mucus membranes can be the result of inadequate hydration, which, like inelastic skin turgor, validates the initial finding of fluid volume deficit.

The nurse proceeds to assessment of the client's hair. The nurse questions the client about use of hair dye. The client confirms the use of hair dye. Which assessment is most important for the nurse to complete? Jarvis, C., Eckhardt, A., & Thomas, P. (2020).Physical examination & health assessment. St. Louis, MO: Elsevier. A. Assess the color distribution of the hair dye. B. Check the client's hair for split ends. C. Observe the texture and distribution of hair growth on the scalp. D. Note the pattern of hair growth around the client's forehead.

C. Observe the texture and distribution of hair growth on the scalp. Dull, dry, sparse hair may be the result of a nutrient deficiency, such as insufficient protein or zinc. These findings would support the nurse's concerns regarding the client's overall nutritional status.

The client points out a small (1 mm), smooth, slightly raised bright red dot located on the abdomen. The client asks the nurse to examine that spot as well. How should the nurse proceed? A. Apply pressure over the lesion and observe for blanching. B. Advise the client to be examined by a healthcare provider. C. Offer assurance that this lesion is not an abnormal finding. D. Determine if the client experienced any trauma at the site.

C. Offer assurance that this lesion is not an abnormal finding. Cherry angiomas are commonly seen on the abdomen, particularly in persons over the age of 30. Angiomas typically increase in number and size with aging and are not a cause for concern.

The nurse questions the client about her symptoms. What should the nurse ask about first? A. History of skin conditions B. What the client has done to treat the itching C. Severity and location of the itching D. Recent exposure to lice or scabies

C. Severity and location of the itching This is the priority question. Itching may be a symptom of a more life threatening problem and the severity needs to be assessed as a priority.

While conversing with the nurse about the situation, the client starts to scratch, and says, "Oh no, this happens sometimes when I get really stressed." What finding should the nurse expect in response to the client's itching? A. Purpura. B. Hirsutism. C. Urticaria. D. Pustules.

C. Urticaria. Urticaria, or hives, are highly pruritic and can appear in response to many stimuli, including emotional stress. Purpura, or bleeding under the skin, does not appear in response to a stressful situation. Hirsutism, or excessive growth of hair, does not occur in response to a stressful situation. Pustules, or lesions that contain pus in the cavity of the lesion, do not appear in response to a stressful situation.

The nurse examines a mole on the client's abdomen. The mole is oval, solid tan, and approximately 2 mm in diameter. The nurse observes multiple moles on the client's skin. What question is most important to ask the client? A. "When did you first notice the presence of the moles?" B. "Do the moles on your arms make you feel self-conscious?" C. "Where are all your moles located?" D. "Have any of your moles changed in size or appearance?"

D. "Have any of your moles changed in size or appearance?" Because a change in the size or appearance of a mole is a danger sign for skin cancer and warrants a referral for medical evaluation, this is the most important question for the nurse to ask.

What action should the nurse perform if rapid facial flushing is observed? A. Observe the color of the sclerae. B. Measure the oxygen saturation. C. Check for loss of skin integrity. D. Ask about any feelings of anxiety.

D. Ask about any feelings of anxiety. Rapid facial and neck flushing are often the result of vasodilation secondary to stress or anxiety.

The nurse observes that the client's skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess? A. Earlobes B. Hair follicles C. Cheeks and skin D. Conjunctivae

D. Conjunctivae Because paleness of the skin can be difficult to detect in persons with dark or tanned skin, the membranes that line the eyelids (conjunctivae) are a good area to assess for pallor.

The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding? A. Ask the client how these burns occurred. B. Palpate the areas for warmth and swelling. C. Immediately measure and record the vital signs. D. Document the location of the bruises and petechiae.

D. Document the location of the bruises and petechiae. Petechiae are very small areas of hemorrhage from superficial capillaries. They may be the result of a bleeding or clotting problem as well as an indication of superficial trauma. The presence of bruising and petechiae on the client's abdomen causes the nurse to suspect that the client may be the victim of abuse.

The nurse observes the overall hair distribution on the client's face and body. There is visible hair growth on the forearms but no visible hair on the lower extremities. The client has thin eyelashes and eyebrows, and fine, downy facial hair. What action should the nurse take in response to these observations? A. Ask the client if the excessive hair growth on the arms is concerning. B. Note the absence of normal hair growth patterns on the client's face. C. Document the areas of alopecia as an indication of the client's poor nutrition. D. Move on to the next area of assessment since the findings are within normal limits

D. Move on to the next area of assessment since the findings are within normal limits The findings are within normal limits, so the nurse should continue the assessment.

The nurse observes raised, pink wheals on the client's neck. How should the nurse respond to this observation? A. Ask if the client has been stung by an insect recently. B. Explain that antibiotics will need to be prescribed. C. Apply a warm compress directly over the wheals. D. Offer assurance that this is a temporary response.

D. Offer assurance that this is a temporary response. Urticaria, or hives, is an inflammatory response that is generally transient. Hives (urticaria) are not caused by insect bites. Antibiotics are not useful in the treatment of hives, an inflammatory response to a number of different stimuli. Antihistamines may be useful to manage the symptoms of urticaria. Warmth will increase vasodilation and worsen the symptoms of this inflammatory response.

The client tells the nurse that the client's partner is 21-years-old. The couple have been involved together for 6 months. After they go out to eat, the client's partner complains that the client is fat and sometimes punches the client in the stomach so that the client will throw up dinner and remember to eat less the next time. To gather data related to the pattern of abuse, what action should the nurse take first? A. Instruct the client that there is no point in denying the pattern of abuse because of the varying colors of the bruises. B. Determine if the client's partner threatened to hurt the client when trying to break up with the partner. C. Ask the client about the client's use of any illegal drugs or frequency of alcohol abuse since they have been dating. D. Provide a calendar for the client to mark the dates when any violent and abusive behavior by the client's partner occurred.

D. Provide a calendar for the client to mark the dates when any violent and abusive behavior by the client's partner occurred. A calendar is a useful visual aid in that it can help the client "see" the frequency of the abuse, and it can help the nurse determine if there is an escalation of violence toward the client. This is the first step when implementing a danger assessment for the client. The client may also be requested to complete a scale of violence to help the nurse assess the magnitude of the abuse.