Assessment Ch. 14 Assessing hair, skin and nails

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) 1. Diameter greater than 6 mm 2. Pink color 3. Asymmetry 4. Notched border

1, 3, 4

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. 1. Notify the physician 2. Keep to the established care plan 3. Modify nursing interventions 4. Evaluate the client's outcomes 5. Document the findings

3&4

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.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is: A. Blue B. Red C. Yellow D. Purple

A. Blue

Short, pale, and fine hair that is present over much of the body is termed: A. lanugo B. vellus C. dermal D. terminal

B

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: A. Bullae B. Vesicles C. Nodules D. wheals

B

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? A. Beau's lines B. Clubbing C. Paronychia D. Spooning

D

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely? A. Seborrheic keratosis B. Basal cell carcinoma C. Actinic keratosis D. Squamous cell carcinoma

A

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: A. nail beds B. Sclera C. oral mucosa D. palms

C

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? A. Sunlight B. Artificial light C. Wood's light D. Flashlight

C

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? A. tinea versicolor B. herpes simplex C. multiple nevi D. tinea corporis

D

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? A. Herpes zoster B. Viral Exanthem C. Psoriasis D. Impetigo

D. impetigo

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

Macules

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply. 1. Use sunlight, if possible, to inspect the skin 2. Have the client remove his toupee 3. Ask the client to remove only his shirt 4. Wear gloves when palpating lesions 5. Have the client stand for the entire examination 6. Keep the room door closed

1, 2, 4, 6

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. 1. Aids in maintaining body temperature 2. Circulates blood throughout the body 3. Involved in digestion of food 4. Largest organ of the body 5. Protects against damage to the body from sunlight 6. Helps make vitamin D in the body

1,4,5,6

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? A. Psoriasis, fungal infections, trauma B. Eczema, melanoma, herpes zoster C. Vitiligo, hirsutism, vitamin deficiency D. Alopecia, dermatitis, chemotherapy

A

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? A. Pustular acne B. Cystic acne C. Bullous impetigo D. Chickenpox

A

What is the most important focus area for the integumentary system? A. moles with defined borders smaller than 6 mm B. UV radiation exposure C. washing the face and hands D. chemical exposure

B

Which of the following assessment findings most likely constitutes a secondary skin lesion? A. Facial lesions associated with herpes simplex B. Keloid formation at the site of an old incision C. Facial acne D. Psoriasis

B

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? A. "Sometimes moles change as you age" B. "How has it changed?" C. "Do you know how to check for signs of skin cancer?" D. "When did you notice the change?"

B

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

Osteomyelitis