Med Surg I Prep U Chapter 60: Assessment of Integumentary Function

During an interview, a middle-aged male patient states, "My hair is starting to turn gray." The nurse demonstrates understanding of this change by responding with which statement?

"As you get older, your hair begins to lose its pigment."

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?"

The nurse is teaching health promotion to a class on osteoporosis prevention. The nurse determines that the participants understand the teaching when they identify that clients need how much sun exposure to synthesize sufficient vitamin D?

5 to 30 minutes twice a week

Which of the following describes a total absence of pigment melanin?

Albinism

Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate?

Beard

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

Bronze

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?

Clubbing

A client has an elevated temperature. The nurse is applying a cool compress to his forehead. This is an example of which of the following types of heat loss?

Conduction

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?

Conduction

Which term describes the transfer of heat from the body to a cooler object in contact with it?

Conduction

Which type of heat loss is caused by a cool breeze that blows across the body surface?

Convection

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?

Elevated and palpable

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?

Evaporation

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?

Freckles

What body structures have keratin as part of their composition?

Hair, skin, fingernails

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding?

Hirsutism

Which layer of the skin is made of primarily adipose tissue?

Hypodermis

Production of melanin is controlled by a hormone secreted by which of the following?

Hypothalamus

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

Hypoxia

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding?

Iron deficiency anemia

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?

Jaundice

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid

While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. The nurse interprets this as which of the following?

Liver spots

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?

Macule

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?

Make sure that the room is darkened.

Which of the following is the most common cause of hair loss?

Male pattern baldness

Which of the following pigments influences hair color?

Melanin

To detect cyanosis in clients with dark skin, the nurse should assess which area?

Oral mucosa

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding?

Pearly white substance that is attached to the hair shaft that is not removed with brushing

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?

Petechiae

The nurse is assessing the fingernails of a patient at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of?

Psoriasis

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?

Pustule

A nurse is assessing a patient with impetigo. The nurse would most likely observe which of the following?

Pustule

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition?

Reduction in sebum production

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?

Spider angioma

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull.

Petechiae are associated with which of the following disorders?

Thrombocytopenia

Which of the following diagnostics is used to examine cells from herpes zoster?

Tzanck smear

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?

Vitiligo

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is a symptom of what?

Vitiligo

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?

Yellowish waxy deposits on the eyelids

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as

petechiae

A 15-year old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum?

prevents drying and cracking of the skin and hair

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as

vesicles