114 Chapter 14
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 mild moderate negligible
A
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast entire skin surface soles of the feet adipose tissue.
A
A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) Lymphatic vessels Connective tissue Vernix Blood vessels Sweat glands
A,D,E
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears Greenish Ashen bluish olive.
B
An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) Depth Location Other lesions on body Size Texture
B,D,E
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? Stratum corneum Stratum lucidum Dermis Epidermis
C
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? Reynaud disease Central cyanosis Neurofibromatosis Peripheral cyanosis
D
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 Ask further questions Document the statement Move on to next body system
A
Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? Acne Psoriasis Varicella Herpes simplex
A
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? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus
B
During an assessment the nurse performs the action shown in this image. What is the purpose of this action? Monitor oxygen status Determine capillary refill Assess finger range of motion Measure nerve function in the fingers
B
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? heart sounds bowel sounds pulse oximetry body temperature
C
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Type Color Distribution Arrangement
C
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? Newton scale Head-to-toe assessment Norton scale Braden scale
D
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 ulcers. erosion. scales. Fissures.
D
Hair follicles, sebaceous glands, and sweat glands originate from the Epidermis eccrine glands keratinized tissue Dermis
D
To assess an adult client's skin turgor, the nurse should press down on the skin of the feet use the dorsal surfaces of the hands on the client's arms use the finger pads to palpate the skin at the sternum use two fingers to pinch the skin under the clavicle.
D
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? The damage to keratin producing cells in the epidermis layer Destruction of hair follicles located in the dermis layer The impairment of apocrine gland to function effectively in the subcutaneous layer The ability of the adipose layer to produce carotene has been destroyed
B
A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color? Capillary blood flow Carotene Melanin Collagen
C
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Deoxyhemoglobin Carotene Melanin
C
The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action? Lower the head of bed and pull the client up with both arms. Place the client in Trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client. Push the client toward the head of the bed to prevent back injury.
C
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? Anterior chest Upper abdomen On the neck Under the breast
D
When documenting that a client has freckles, the appropriate term to use is macules patches vesicles bullae
A
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 Nodules Bullae Vesicles Wheals
C
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Artificial light Wood's light Flashlight
C
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 lice ticks Allergies
A
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 Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy
A
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 The client has melanoma The client has COPD The client has asthma
A
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. The client is elderly The client may have peripheral vascular disease The client may have a cognitive deficit.
A
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 a mild degree of cyanosis lupus erythematosus Hyperthyroidism
A
The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? The client exhibits no signs or symptoms of infection The client changes position every 2 hours The client keeps the area clean and dry The client knows prevention measures for pressure ulcers
A
The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin? dermis adipose epidermis Subcutaneous
A
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea Diaphoresis
A
What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands
A
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer
A
Which of the following is an important function of the skin? Synthesis of vitamin D Production of carotene Maintenance of acid-base balance Protection against melanin deposits
A
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. trauma. anemia. infection.
A
Why is it important for the nurse to ask the client what they think caused a skin condition? The client's perception affects the approach and effectiveness in treating the skin condition The nurse can alleviate the client's fears about what caused the skin condition Doing so allows the client to decide what treatment is the best course of action Doing so encourages the client to use home remedies to reduce medical cost
A
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Vitiligo, hirsutism, vitamin deficiency Psoriasis, fungal infections, trauma Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy
B
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? Insect bites Urticaria or hives Psoriasis Purpura
B
The student nurse learns that examining the skin can do all of the following except? Reveal overhydration Allow early identification of neurologic deficits Identify physical abuse Allow early identification of potentially cancerous lesions
B
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? 1 2 3 4
C
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? Small lesion left forearm for one month Denies any skin color changes Skin warm and dry to the touch Dry and flaky skin in the winter months
C
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Linear Annular Clustered Discrete
C
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? Eczema Pityriasis rosea Psoriasis Tinea infection
C
The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action? Lower the head of bed and pull the client up with both arms Place the client in Trendelenburg so the client can slide up in bed Call for help and use the draw sheet to move the client Push the client toward the head of the bed to prevent back injury.
C
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? Allow the client to pray before the examination Let the client remained fully dressed for the examination Have a nurse who is the same sex as the client examine him Avoid asking any questions regarding the client's lifestyle
C
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? Assess the client for changes in sensation due to vascular problems Monitor the client for additional findings of cystic fibrosis Suggest that the client use antiperspirant products Document the findings in the client's record as normal
D
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? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister
D
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? Moist and smooth Moist and rough Dry and smooth Dry and rough
D
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body? palms of the hands face soles of the feet Underarms
D