Ch. 9: Integumentary System

changes of hair in pubic or axilla suggests:

hormonal problems

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 wheals. bullae. nodules. vesicles.

vesicles

The skin is recognized for performing which function? A. Temperature control B. Synthesizes vitamin K C. Excretion of excessive electrolytes D. Motor perception

A. Temperature control The functions of the skin include synthesis of vitamin D from sunlight, provide a barrier of protection, regulate body temperature, sensory perception, provide identity, allow wound repair, and allow excretion of metabolic waste.

ABCDE-EFGs of Examining Moles for Possible Melanoma

A: Asymmetry of one side of mole compared to other B: Irregular borders, especially ragged, notched, blurred C: Variation or change in color, especially black or blue D: Diameter ≥6 mm or different from others, especially if changing, itching, or bleeding E: Evolving, a mole or skin lesion that looks different from the rest or is changing in size, shape, or color Suggested adding EFG to help detect aggressive nodular melanomas E: Elevated F: Firm to palpation G: Growing progressively over several weeks

Nonpitting edema

local infection or trauma; brawny edema

loss of hair on the legs suggests:

peripheral artery disease

Classification of lesions: vascular/purpuric

acquired lesions or lesion present at birth related to underlying tissue or blood vessels (spider veins, petechia)

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? "Do you take steroid medications on a regular basis?" "Have you ever been assessed for diabetes?" "What dietary supplements do you usually take?" "Has anyone in your family ever been diagnosed with skin cancer?"

"Do you take steroid medications on a regular basis?"

Vesicles in a unilateral dermatomal pattern are typical of: A. Herpes zoster B. Herpes simplex C. Tinea capitis D. Acne vulgaris

A. Herpes zoster Herpes zoster (also known as shingles) forms vesicles that follow a dermatome of the body, usually trunk. These usually occur on only one side of the body (unilateral).

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Cushing syndrome Alcoholism Parkinson's disease Marfan syndrome

Alcoholism

To prevent skin cancer, a sunscreen with a "skin protection factor" (SPF) of _____ is recommended. A. 10 B. 20 C. 30 D. 40

C. 30 An SPF of at least 30 and broad-spectrum protection is recommended.

During your physical examination of the patient, you gently pinch the back of the hand. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of: A. Infection B. Overhydration C. Dehydration D. Properly hydrated

C. Dehydration "Tenting" is a sign of poor turgor and occurs when a patient is dehydrated, often occurring with excessive vomiting, diarrhea, or heat-related situations. The patient should be further assessed for the need of intravenous fluids.

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 Lupus erythematosus Cushing's disease Basal cell carcinoma

Cushing's disease

Edema

Excess fluid in interstitial spaces

The nurse is preparing to examine a client's skin. What would the nurse do next? Have the client remove clothing from the upper body. Expose only the body part that is being examined. Wear gloves when preparing to inspect the skin and nails. Ensure that the room is hot to prevent chilling.

Expose only the body part that is being examined.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous cells Sebum production Subcutaneous tissue Sweat glands

Sebum production

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? Vasoconstriction Cardiopulmonary insufficiency Hypoxemia Hyperglycemia

Vasoconstriction

Classification of lesions: secondary

arises from primary lesion (scars, keloids, crust, fissure, ulcer)

Localized edema

from injury

What makes up the integumentary system?

hair, nails, skin

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of infectious conditions. hyperthyroidism. hypoparathyroidism. hypothyroidism.

hypothyroidism

Classification of lesions: primary

initial lesion (papule, nodule, cysts, atopic eczema)

Pitting edema

interstitial fluid mobile

Systemic edema

most often in the dependent portions of body Skin puffy and feels tight

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: recent radiation therapy. pigmentation irregularities. symptoms of stress. allergies to certain foods.

symptoms of stress.

Functions of the skin

•Provides a barrier •Regulates body temperature •Synthesizes vitamin D •Sensory perception •Provides nonverbal communication •Provides identity •Allows wound repair •Allows excretion of metabolic wastes