Ch14-PU

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? a) Tinea infection b) Pityriasis rosea c) Psoriasis d) Eczema

Psoriasis Explanation: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

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) Alopecia, dermatitis, chemotherapy c) Eczema, melanoma, herpes zoster d) Vitiligo, hirsutism, vitamin deficiency

Psoriasis, fungal infections, trauma Explanation: Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had a recent illness. radiation. chemotherapy. steroid therapy.

a recent illness

Short, pale, and fine hair that is present over much of the body is termed

vellus

The student nurse learns that examining the skin can do all of the following except? Reveal overhydration Identify physical abuse Allow early identification of neurologic deficits Allow early identification of potentially cancerous lesions

Allow early identification of neurologic deficits

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy? a) Melasma is always permanent b) Melasma should be treated with antibiotics c) Melasma can be treated with Betadine ointment d) Melasma generally resolves postpartum

Melasma generally resolves postpartum Explanation: Melasma, increased pigmentation of the face in response to the hormonal changes of pregnancy, occurs mainly on the chin, cheeks, and upper lip and generally resolves postpartum but can be permanent. Melasma is not a condition that is treated with Betadine or antibiotics

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

A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following? a) Flushed b) Thin c) Pale d) Thick

Thin Explanation: Thin skin is most likely to be assessed because of decreased protein and subcutaneous fat secondary to glucocorticoid drugs. The skin would not be pale or flushed

The nurse should implement which technique when assessing for jaundice in a dark-skinned patient diagnosed with liver disease?

assessing the client's hard palate with a bright light

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? a) "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." b) "Repeated sunburns in childhood may explain the presence of some of your moles." c) "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." d) "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Explanation: Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as a) 13 b) 15 c) 9 d) 11

15

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? a) 9 or lower b) 10 to 12 c) 19 to 23 d) 13 to 18

19 to 23 Explanation: Levels of risk for developing pressure ulcers are rated according to the following scores: • 19 to 23: not at risk • 15 to 18: mild risk • 13 to 14: moderate risk • 10 to 12: high risk • 9 or lower: very high risk

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? a) 1 b) 2 c) 3 d) 4

3 Explanation: 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.

A nurse cares for a client of Asian decent 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? a) Document the findings in the client's record as normal b) Ask the client about overuse of antiperspirant products c) Assess the client for changes in sensation due to vascular problems d) Monitor the client for additional findings of cystic fibrosis

A Explanation: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucous, especially in the lungs. Overuse of antiperspirants would be needed for excessive sweating, not decrease in sweating. (less)

Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what? a) Psoriasis b) Herpes simplex c) Acne d) Varicella

Acne Explanation: Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex are vesicular lesions and psoriasis are plaque lesions.

A 68-year-old retired farmer comes to the office for evaluation of a skin lesion. On the right temporal area of the forehead is a flattened papule the same color as his skin, covered by a dry, round scale that feels hard. He has several more of these scattered on the forehead, arms, and legs. Based on this description, what diagnosis is most likely? a) Actinic keratosis b) Squamous cell carcinoma c) Basal cell carcinoma d) Seborrheic keratosis

Actinic keratosis Explanation: This is a typical description of actinic keratosis, which may be easier to feel than to see. If left untreated, approximately 1% can develop into squamous cell carcinoma.

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behaviour at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? a) Alopecia areata b) Tinea capitis c) Trichotillomania d) Traction alopecia

Alopecia areata Explanation: This is a typical description for alopecia areata. There are no risk factors for trichotillomania or traction alopecia. The physical examination is not consistent with tinea capitis, because the skin is intact.

Recommended protective measures to avoid skin cancer include which of the following? a) Avoiding sun exposure b) Performing monthly skin self-examinations c) Seeking biannual examination by a clinician after age 40 years d) Knowing signs of skin cancer

Avoiding sun exposure Explanation: While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red colour remains. What should the nurse do? a) Prescribe a steroid cream to decrease inflammation. b) Tell him not to scratch them and follow up in 3 days. c) Consider admitting the client to the hospital. d) Reassure the parents and the client that this should resolve within 1 week.

Consider admitting the client to the hospital. Explanation: Although this rash may not be impressive, the fact that they do not "blanch" with pressure is concerning. This generally means that there is pinpoint bleeding under the skin; while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. The nurse should always report this feature of a rash immediately

A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? a) Basal cell carcinoma b) Lupus erythematosus c) Cushing's disease d) Iron deficiency anemia

Cushing's disease Explanation: Hirsuitism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

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? a) Iron deficiency anemia b) Cushing's disease c) Lupus erythematosus d) Basal cell carcinoma

Cushing's disease Explanation: Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process? a) Hypothyroidism b) Psoriasis c) Contact dermatitis d) Diabetes mellitus

Diabetes mellitus Explanation: The appearance of a rough and dark skin around the neck area, especially in African Americans, can be an indication of diabetes mellitus. This condition is called acanthosis nigricans. Psoriasis is a skin condition caused by overgrowth of desquamated, dead epithelium skin cells and causes a silvery white appearance to the skin. Hypothyroidism causes a generalized dryness to the skin. Contact dermatitis is a thickening and roughness of the skin caused by exposure to a substance that is an allergen, chemical, foods, or emotional stress.

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? a) Confluent b) Discrete c) Linear d) Annular

Discrete Explanation: Lesions that are individual and distinct display a discrete configuration. Lesions in a linear configuration appear in a straight line such as in a scratch or streak. Lesions in an annular configuration appear in a circle. Lesions in a confluent configuration run together.

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 consequently ask? a) "What dietary supplements do you usually take?" b) "Do you take steroid medications on a regular basis?" c) "Have you ever been assessed for diabetes?" d) "Has anyone in your family ever been diagnosed with skin cancer?"

Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

The apocrine glands are stimulated by what? a) Physical stress b) Temperature c) Overhydration d) Emotional stress

Emotional stress Explanation: The eccrine glands are widely distributed, open directly onto the skin surface, and by their sweat production help to control body temperature. In contrast, the apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress.

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system? a) Cardiovascular b) Genitourinary c) Neurologic d) Endocrine

Endocrine Explanation: Excess body hair on the face and chest (masculine pattern of hair distribution) is suggestive of possible hormonal dysfunction. The nurse would need to assess the client's endocrine system and function and likely refer her to endocrinology

When preparing to examine a client's skin, which of the following would be most important for the nurse to do? a) Ensure that the room is warm to prevent chilling b) Wear gloves when preparing to inspect the skin and nails c) Have the client remove clothing from the upper body d) Expose only the body part that is being examined

Expose only the body part that is being examined Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify which of the following as an example? a) Cutaneous tags b) Striae c) Vitiligo d) Fissure

Fissure Explanation: A fissure, a linear crack in the skin that may extend to the dermis, is considered an abnormal finding. Common variations include cutaneous tags, striae, and vitiligo.

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? a) Avoid asking any questions regarding the client's lifestyle b) Allow the client to pray before the examination c) Have a nurse who is the same sex as the client examine him d) Let the client remained fully dressed for the examination

Have a nurse who is the same sex as the client examine him Explanation: Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle

When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient? a) He has peripheral artery disease b) He has a hormonal imbalance c) He has hypothyroidism d) He has hyperthyroidism

He has peripheral artery disease Explanation: Loss of hair on the legs may indicate peripheral artery disease, while changes in pubic or axilla hair may indicate hormonal problems.

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? a) Apply hydrogen peroxide to see whether the client's pruritus is relieved. b) Illuminate the area using a Wood's light. c) Test whether gentle abrasion with an emery board is painful. d) Perform a trial with a topical antibiotic.

Illuminate the area using a Wood's light. Explanation: A Wood's light is used to assess for fungal lesions. Testing for sensitivity and applying antibiotics or hydrogen peroxide will not reveal a fungal etiology.

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) Impetigo b) Herpes zoster c) Viral Exanthum d) Psoriasis

Impetigo Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate & is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral infection.

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? a) Iron deficiency anemia b) Diabetes mellitus c) Peripheral vascular disease d) Vitamin A deficiency

Iron deficiency anemia Explanation: Spoon nails or nails that are thin and concave are associated with iron deficiency, not vitamin A deficiency, peripheral vascular disease, or diabetes mellitus.

Which of the following assessment findings most likely constitutes a secondary skin lesion? a) Facial lesions associated with herpes simplex b) Facial acne c) Psoriasis d) Keloid formation at the site of an old incision

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

Which of the following assessment findings most likely constitutes a secondary skin lesion? a) Psoriasis b) Facial acne c) Facial lesions associated with herpes simplex d) Keloid formation at the site of an old incision

Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

The nurse inspects the skin of an older adult client and notes thick, rough skin over the elbows. The nurse would document this finding as which of the following? a) Crust b) Lichenification c) Atrophy d) Erosion

Lichenification Explanation: Lichenification is characterized by thickening and roughening of the skin, and accentuated skin markings. Crust is characterized by a dried residue of serum, blood, or pus on the skin surface; atrophy by a thin, dry, transparent appearance of the skin and loss of surface markings; and erosion by loss of the superficial epidermis.

A nurse receives a report from the shift nurse that a client has new onset of peripheral cyanosis. The nurse recognizes that which of the following is the most likely underlying cause? a) Skin cancer b) Local vasoconstriction c) Cardiopulmonary problem d) Diabetes mellitus

Local vasoconstriction Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Central cyanosis results from a cardiopulmonary problem. Diabetes mellitus and skin cancer are not associated with peripheral cyanosis.

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next? a) Conclude this is caused by a cultural practice. b) Ask about dietary intake. c) Look for information from family and records regarding any problems that may have occurred at least 3 months ago. d) Conclude this finding is most likely secondary to trauma.

Look for information from family and records regarding any problems that may have occurred at least 3 months ago. Explanation: These lines can provide valuable information about previous significant illnesses, some of which are forgotten or not able to be reported by the client. Because the fingernails grow at approximately 0.1 mm per day, the nurse would ask about an illness 100 days ago. This client may have been hospitalized for endocarditis or may have had another significant illness. Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a client's culture without good knowledge of that culture

A patient's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the patient's risk for pressure sore development is: a) No risk b) Mild risk c) High risk d) Moderate risk

Mild risk Explanation: The Braden Scale assesses six factors for the development of pressure sores: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The higher the score, the lower the risk. A score of 19 to 23 would be no risk. A score of 15 to 18 would be mild risk. The patient's score is 16, which is a mild risk. A score of 13 to 14 is moderate risk. A score of 10 to 12 is a high risk.

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? a) Nail beds b) Palms c) Sclera d) Oral mucosa

Oral mucosa Explanation: Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists it may indicate systemic hypoxemia. Peripheral cyanosis that results from vasoconstriction would most likely be noted in the nailbeds and conjunctival areas.

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. The nurse would document this finding as which of the following? a) Macule b) Nodule c) Papule d) Pustule

Papule

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following would the nurse do next? a) Document the benign findings. b) Ask the client about a family history of cancer. c) Perform a random blood sugar test. d) Refer the client for medical follow-up.

Perform a random blood sugar test. Explanation: Linear hyperpigmented areas (Acanthosis nigricans) present in the skin of the neck, axillae, and perianal folds in dark-skinned people suggest diabetes mellitus. A random blood sugar test would provide an objective assessment to identify hyperglycemia. The findings are not indicative of skin cancer, nor are they benign. The client may be referred for medical follow up after additional assessment is completed.

In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds? a) Multiple sclerosis b) Peripheral vascular disease c) Malignant melanoma d) Psoriasis

Peripheral vascular disease Explanation: Peripheral vascular disease decreases the circulation of the periphery of the body, causing hypoxia and a capillary refill of greater than 2 seconds. Psoriasis, multiple sclerosis, and malignant melanoma are not associated with changes in capillary refill.

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? a) Cherry angioma b) Petechiae c) Ecchymosis d) Purpura

Petechiae Explanation: Petechiae are small, round, red or purple macules that are secondary to blood extravasation. Purpura refers to hemorrhagic disease that produces ecchymoses and petechiae. Ecchymosis refers to round or irregular macular lesions that are larger than petechiae and are variable in color. A cherry angioma is a papular round red or purple lesion.

A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis? a) Psoriasis b) Atopic eczema c) Pityriasis rosea d) Tinea versicolor

Pityriasis rosea Explanation: This is a classic description of pityriasis rosea. The description of a large single or "herald" patch preceding the eruption is a good way to distinguish this rash from other conditions

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient? a) Chickenpox b) Bullous impetigo c) Pustular acne d) Cystic acne

Pustular acne Explanation: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

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? a) Sebum production b) Sweat glands c) Squamous cells d) Subcutaneous tissue

Sebum production Explanation: Sebum production decreases with age, therefore increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown? a) Excessive sweating on a dependent body region b) Loss of the dermis c) Eschar on an area near a bony prominence d) Skin that feels boggy on palpation

Skin that feels boggy on palpation Explanation: Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.

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? a) Skin warm and dry to the touch b) Dry and flaky skin in the winter months c) Small lesion left forearm for one month d) Denies any skin color changes

Skin warm and dry to the touch Explanation: Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

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? a) Transverse white lines in the nails b) White spots, or leukonychia, on the nail surfaces c) Beau's lines d) Small pits in the surfaces of the nails

Small pits in the surfaces of the nails Explanation: 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.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? a) Spooning b) Clubbing c) Paronychia d) Beau's lines

Spooning Explanation: Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis? a) Stratum granulosum b) Stratum lucidum c) Stratum germinativum d) Stratum corneum

Stratum corneum Explanation: The epidermis consists of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum, in that order.

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment? a) Tenting indicates dramatic weight loss b) Tenting indicates dehydration c) Tenting indicates vitamin B12 deficiency d) Tenting indicates malnutrition

Tenting indicates dehydration Explanation: A persistent pinch, or tenting of the skin, indicates dehydration. Tenting would not be present in the condition of malnutrition alone, dramatic weight loss, or vitamin B12 deficiency.

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse? a) This is not lice; it is scabies b) The client had a recent infestation c) The nits indicate the infestation is over d) The client has had lice for quite some time

The client had a recent infestation Explanation: The closer to the scalp the nit is located, the more recent the infestation. The client is not presenting with lice which have been present for a long time or that the infestation is over. The client is not presenting with scabies

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? a) The client has COPD b) The client has melanoma c) The client has chronic hypoxia d) The client has asthma

The client has chronic hypoxia Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

A client comes to the ICU. The nurse assesses the client using the Braden skin assessment scale and the score is 15. What does this information tell the nurse? a) The client is at low risk for pressure ulcer development b) The client is at medium risk for pressure ulcer development c) The client is at high risk for pressure ulcer development d) The client is not at risk for pressure ulcer development

The client is at high risk for pressure ulcer development Explanation: A score of 14 to 18 on the Braden scale indicates a high risk of pressure ulcer development.

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? a) The client adheres to a vegetarian diet. b) The client is consistently incontinent of urine. c) The client has a full-time caregiver. d) The client has a surgical diagnosis.

The client is consistently incontinent of urine. Explanation: The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? a) The pigmentation of the client's skin b) The client's ability to change position c) The client's current medication regimen d) The client's history of integumentary disorders

The client's ability to change position Explanation: The Braden Scale appraises the client's level of mobility but does not directly include data related to medications, history of skin disorders, or pigmentation.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate? a) The elderly should bathe or shower only every 2 to 3 days b) The elderly should only bathe or shower once a week c) The elderly should bathe or shower once every 2 weeks d) The elderly should bathe or shower daily but use lots of moisturizer

The elderly should bathe or shower only every 2 to 3 days Correct Explanation: Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? a) The lesions will not be palpable. b) The lesions will be raised and have irregular borders. c) The lesions will produce eschar. d) The lesions will be acutely painful.

The lesions will not be palpable. Explanation: Macules are small, flat, nonpalpable areas of skin color change. They are not normally painful and do not produce eschar.

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) Herpes simplex b) Tinea corporis c) Tinea versicolor d) Multiple nevi

Tinea corporis Explanation: In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

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? a) Upper abdomen b) Anterior chest c) Under the breast d) On the neck

Under the breast Explanation: The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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? a) Insect bites b) Psoriasis c) Purpura d) Urticaria or hives

Urticaria or hives Explanation: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions "move" from place to place. This would be distinctly unusual for the other causes listed.

A client reports that he might have shingles. Which type of lesion would the nurse most likely assess? a) Papule b) Crust c) Bulla d) Vesicle

Vesicle Explanation: Herpes zoster (shingles) is characterized by grouped vesicular skin eruptions along a cutaneous sensory nerve line. The vesicles typically are less than 0.5 cm. Elevated nevi or warts would be noted as papules. Bulla would be vesicles greater than 0.5 cm. Crust is a dried residue of serum, blood, or pus on the skin, such as what is left after a vesicle ruptures.

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect? a) Vitiligo b) Addison disease c) Dermatomyositis d) Tinea versicolor

Vitiligo Explanation: In vitiligo, depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment is normal skin color; the pale areas are vitiligo. The condition may be hereditary. These changes may be distressing to the patient.

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 nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Parkinsons disease Marfans syndrome Alcoholism Cushings syndrome

alcoholism

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) yellow. b) purple. c) red. d) blue.

blue. Explanation: Blue-green fluorescence indicates fungal infection.

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 a) signs of an infectious process. b) precancerous lesions. c) caused by aging of the skin in older adults. d) signs of dermatitis.

caused by aging of the skin in older adults. Explanation: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to a) melanomas if they reside in areas without ozone depletion. b) chronic discoid lupus erythematosus. c) genetic predisposition to melanomas. d) skin cancers than persons of European origin.

chronic discoid lupus erythematosus. Explanation: Patchy hair loss may result from infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Colour Arrangement Type Distribution

distribution

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate a) calcium. b) vitamin D. c) carbohydrates. d) fluid intake.

fluid intake. Explanation: Adequate fluid intake is required to maintain skin elasticity.

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

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

hypothyroidism

Question: Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1 full-thickness skin loss 2 necrosis with damage to underlying muscle 3 intact, firm skin with redness 4 ulceration involving the dermis

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

A patient with a zosteriform rash has a rash that a) is distributed equally on both sides of the body b) appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion c) is distributed along a dermatome d) has lesions distributed over a large body area

is distributed along a dermatome Explanation: A zosteriform rash is distributed along a dermatome.

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a a) bulla. b) keloid. c) cyst. d) lichenification.

keloid. Explanation: Nodules and tumors are elevated, solid, palpable masses that extends deeper into dermis than a papule. Nodules are 0.5-2 cm and circumscribed; tumors are greater than 1-2 cm and do not always have sharp borders. Examples of nodules include a keloid

The nails, located on the distal phalanges of the fingers and toes, are composed of a) endodermal cells. b) ectodermal cells. c) keratinized epidermal cells. d) stratum cells.

keratinized epidermal cells. Explanation: The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the cuticle

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 a) patch. b) plaque. c) macule. d) papule.

papule. Explanation: Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is a) risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. b) dry flaking skin and dull dry hair as a result of disease. c) anxiety related to loss of outdoor activities and altered skin appearance. d) ineffective individual coping related to changes in appearance.

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. Explanation: Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's a) abdomen. b) arms. c) legs. d) sclera.

sclera. Explanation: Jaundice in light- and dark skinned people is characterized by yellow skin tones, from pale to pumpkin, particularly in the sclera, oral mucosa, palms, and soles.

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that a) African Americans are the least susceptible to skin cancers. b) squamous cell carcinomas are most common on body sites with heavy sun exposure. c) melanoma skin cancers are the most common type of cancers. d) usually there are precursor lesions for basal cell carcinomas.

squamous cell carcinomas are most common on body sites with heavy sun exposure.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as a) stage IV. b) stage I. c) stage III. d) stage II.

stage II. Explanation: 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.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as a) stage II. b) stage IV. c) stage III. d) stage I.

stage II. Explanation: 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.

Connecting the skin to underlying structures is/are the a) sebaceous glands. b) dermis layer. c) papillae. d) subcutaneous tissue.

subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

Local redness of the skin warns of impending necrosis. a) True b) False

true

To assess an adult client's skin turgor, the nurse should a) press down on the skin of the feet. b) use two fingers to pinch the skin under the clavicle. c) use the fingerpads to palpate the skin at the sternum. d) use the dorsal surfaces of the hands on the client's arms.

use two fingers to pinch the skin under the clavicle. Explanation: To assess turgor, gently pinch the skin over the clavicle with two fingers.

hort, pale, and fine hair that is present over much of the body is termed a) dermal. b) vellus. c) terminal. d) lanugo.

vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

he 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) wheals. c) nodules. d) vesicles.

vesicles. Explanation: Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

A client's skin color depends on melanin and carotene contained in the skin, and the a) number of lymph vessels near the dermis. b) vascularity of the apocrine glands. c) volume of blood circulating in the dermis. d) client's genetic background.

volume of blood circulating in the dermis. Explanation: The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.

Upon assessment, the nurse notes the client's skin to be dry and thin. The nurse understands that is is related to what? Select all that apply. a) Increased apocrine production b) Decreased apocrine production c) Decreased turgor d) Increased eccrine production e) Decreased eccrine production

• Decreased eccrine production • Decreased apocrine production Explanation: Part of the aging process includes decreased eccrine and apocrine production which leads to skin dryness Turgor is a measure of elasticity.

The nurse is gathering equipment to perform a skin assessment on an elderly client. What type of equipment will be needed? Select all that apply. a) Magnifying glass b) Adequate light source c) Tape measure d) Eye protection e) Examination gown f) Shoe covers

• Examination gown • Tape measure • Adequate light source • Magnifying glass Explanation: Equipment needed for a skin assessment includes an examination gown, a tape measure, an adequate light source, and a magnifying glass. Eye protection and shoe covers are not necessary.

What does examination of the skin involve? Select all that apply. a) Palpation b) Inspection c) Percussion d) Auscultation e) Nutritional assessment

• Inspection • Palpation Explanation: Examination of the skin involves inspection and palpation. It does not generally involve a nutrition assessment, percussion, or auscultation.

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. a) Helps make vitamin D in the body b) Involved in digestion of food c) Largest organ of the body d) Protects against damage to the body from sunlight e) Circulates blood throughout the body f) Aids in maintaining body temperature

• Largest organ of the body • Protects against damage to the body from sunlight • Aids in maintaining body temperature Helps make vitamin D in the body Explanation: The skin is the largest organ of the body. The skin 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. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food

patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.) a) Synthesis of vitamin D b) Loss of water and electrolytes c) Mechanical or chemical injuries d) Penetration by microorganisms e) Regulation of body temperature

• Mechanical or chemical injuries • Penetration by microorganisms • Loss of water and electrolytes Explanation: The skin provides a barrier protecting the body from injury caused by mechanical or chemical sources, penetration by microorganisms, and the loss of water and electrolytes. Regulation of body temperature is another function of the skin that allows heat to dissipate through sweat glands or permit heat storage through subcutaneous tissue. Synthesis of vitamin D is another function of the skin that occurs from cholesterol by the action of ultraviolet light. While the skin is a factor in both Vitamin D synthesis and in the regulation of body temperature neither are considered barrier functions of the skin. (

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. a) Use sunlight, if possible, to inspect the skin b) Wear gloves when palpating lesions c) Keep the room door closed d) Ask the client to remove only his shirt e) Have the client stand for the entire examination f) Have the client remove his toupee

• Use sunlight, if possible, to inspect the skin • Have the client remove his toupee • Wear gloves when palpating lesions • Keep the room door closed Explanation: To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on an examination gown. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. The client may remain in a sitting position for most of the examination. If available, sunlight is best for inspecting the skin. Wear gloves when palpating any lesions because you may be exposed to drainage. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) a) diameter great than 6 cm b) pink color c) notched border d) asymmetry

• asymmetry • diameter great than 6 cm • notched border