Assessment Ch 14
A stage II pressure ulcer results in a
superficial skin loss of the epidermis alone or the dermis also.
Cyanosis may cause
white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas.
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
D
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
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
Areola of breast
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
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?
Client has chronic hypoxia
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 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
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
Fainting
After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)
Location Distribution pattern Elevation Color
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
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
The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?
Signs and symptoms of melanoma
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 since infection is a risk for additional injury
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
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
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light
Beneath the dermis lies the subcutaneous tissue,
a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.
Papules are
also elevated, palpable, sold masses, but are smaller than 0.5 cm
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 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.
In an annular configuration, the lesion is
circular; an example is tinea corporis (ringworm)
A client with hypothyroidism is expected to have
dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.
Plaques are
elevated, palpable, solid masses greater than 0.5 cm and may be coalesced papules with a flat top.
A stage III ulcer is a
full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.
In a discrete configuration, the lesions are
individual and distinct; an example is multiple nevi.
The nails, located on the distal phalanges of the fingers and toes, are composed of
keratinized epidermal cells.
Small pits in the nails are an early sign of, though not specific for,
psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.
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
Malignant melanomas are evaluated according to the mnemonic ABCDE:
A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated
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?
Clustered
Hirsutism, or facial hair on females, is a characteristic of
Cushing's disease and results from an imbalance of adrenal hormones
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
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
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
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
Hypothyroidism
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 tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area
When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)
Red or light hair Freckles Immunosuppression
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
Carotene is
a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.
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
Pallor (loss of color) is seen in
arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.
Stage III pressure ulcers involve the
epidermis, dermis, and subcutaneous tissue
A Stage IV pressure ulcer has .
full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed
· Risk factors for melanoma:
history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sun exposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.
If the client has a specific concern about the skin, the nurse should
inspect the area/lesion first and ask other questions second
The subcutaneous layer provides
insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility.
A Stage I pressure ulcer has
intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Stage IV ulcers can extend into muscle and/or supporting structures, making
osteomyelitis possible
A Stage II pressure ulcer is a
partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister.
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:
plaque
Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a
shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
A stage I pressure ulcer is red in color but without
skin breakdown.
Macules and patches are
small, flat, nonpalpable skin color changes.
The second layer, the dermis, functions as
support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function.
Examination of the skin can reveal signs of
systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.
The skin is the largest organ of the body. It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in:
temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis
Short, pale, and fine hair that is present over much of the body is termed
vellus