Chapter 11
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?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 273. Chapter 11: Skin, Hair, and Nails - Page 273
sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Repeated sunburns in childhood may explain the presence of some of your moles. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older."
"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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 254. Chapter 11: Skin, Hair, and Nails - Page 254
An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "It means you have skin cancer and need to have them removed." "These are considered a normal age-related change in the skin." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."
"These are considered a normal age-related change in the skin." Explanation: Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 245. Chapter 11: Skin, Hair, and Nails - Page 245
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 4ulceration involving the dermis 3full-thickness skin loss 2intact, firm skin with redness 1necrosis with damage to underlying muscle
1)intact, firm skin with redness 2)ulceration involving the dermis 3)full-thickness skin loss 4)necrosis with damage to underlying muscle Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 263. Chapter 11: Skin, Hair, and Nails - Page 263
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? 2 4 1 3
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 258. Chapter 11: Skin, Hair, and Nails - Page 258
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? Alcoholism Parkinson's disease Marfan syndrome Cushing syndrome
Alcoholism Explanation: A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails.
The student nurse learns that examining the skin can do all of the following except? Reveal overhydration Allow early identification of neurologic deficits Allow early identification of potentially cancerous lesions Identify physical abuse
Allow early identification of neurologic deficits Explanation: 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 265. Chapter 11: Skin, Hair, and Nails - Page 265
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 behavior 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? Alopecia areata Tinea capitis Trichotillomania 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 290. Chapter 11: Skin, Hair, and Nails - Page 290
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? Are you allergic to foods, medications, or other substances? "What have you been doing to control the itching?" "Have you ever had a rash like this before?" "Does anyone else in your family have a rash like this?"
Are you allergic to foods, medications, or other substances? Explanation: The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information such as a history of a previous or similar rash and measures to address the itching. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 253. Chapter 11: Skin, Hair, and Nails - Page 253
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma? Color is uniform Borders well demarcated Asymmetrical shape Diameter less than 6mm
Asymmetrical shape Explanation: 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 to1/4 inch (3-4mm), and E for elevated. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 247. Chapter 11: Skin, Hair, and Nails - Page 247
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
Broken with the presence of a blister Explanation: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 258. Chapter 11: Skin, Hair, and Nails - Page 258
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 Linear Annular Discrete
Clustered Explanation: In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 276. Chapter 11: Skin, Hair, and Nails - Page 276
An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of? Coining Body piercing Home remedy Henna tattooing
Coining Explanation: Coining, in which clients rub a coin or other specific object across the skin in a particular manner to treat various health concerns, frequently results in bruising and abrasions. It is often mistaken as a sign of physical abuse. This scenario does not describe henna tattooing, body piercing, or home remedy as the cause of the bruises. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 246. Chapter 11: Skin, Hair, and Nails - Page 246
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 Explanation: Hirsutism, 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 269. Chapter 11: Skin, Hair, and Nails - Page 269
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 Epidermis Dermis
Dermis Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Subcutaneous layer Dermis Epidermis Connective layer
Dermis Explanation: 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. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. 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. The connective layer is a distracter to the question. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Distribution Type Arrangement Color
Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 256. Chapter 11: Skin, Hair, and Nails - Page 256
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 rough Moist and smooth Dry and smooth Dry and rough
Dry and rough Explanation: 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 268. Chapter 11: Skin, Hair, and Nails - Page 268
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? Continuous trauma Decreased subcutaneous tissue Excessive collagen formation Inadequate circulation
Excessive collagen formation Explanation: Keloids are caused by excessive collagen formation during the healing process, not from continuous trauma, decreased subcutaneous tissue, or inadequate circulation. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 254. Chapter 11: Skin, Hair, and Nails - Page 254
When preparing to examine a client's skin, which of the following would be most important for the nurse to do? Ensure that the room is warm to prevent chilling 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
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 254. Chapter 11: Skin, Hair, and Nails - Page 254
The nurse is preparing to examine a client's skin. What would the nurse do next? Wear gloves when preparing to inspect the skin and nails. Have the client remove clothing from the upper body. Ensure that the room is hot to prevent chilling. 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 252. Chapter 11: Skin, Hair, and Nails - Page 252
The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? Hypoxia Vitamin C deficiency Infection A normal finding
Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 261. Chapter 11: Skin, Hair, and Nails - Page 261
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Ask further questions Inspect the area Document the statement Move on to next body system
Inspect the area Explanation: If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 247. Chapter 11: Skin, Hair, and Nails - Page 247
A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? Vesicle Macule Papule Nodule
Macule Explanation: A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 270. Chapter 11: Skin, Hair, and Nails - Page 270
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Palms Nail beds Oral mucosa Sclera
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 245. Chapter 11: Skin, Hair, and Nails - Page 245
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed? Osteoarthritis Osteopenia Osteomyelitis Osteoporosis
Osteomyelitis Explanation: This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible. This ulcer does not increase the client's risk for developing osteopenia, osteoporosis, or osteoarthritis. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 260. Chapter 11: Skin, Hair, and Nails - Page 260
A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?
Peripheral cyanosis Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 267. Chapter 11: Skin, Hair, and Nails - Page 267
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Cherry angioma Cutaneous horn Seborrheic keratosis Pressure ulcer
Pressure ulcer Explanation: An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 269. Chapter 11: Skin, Hair, and Nails - Page 269
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 Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy Psoriasis, fungal infections, trauma
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 289. Chapter 11: Skin, Hair, and Nails - Page 289
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? Sebum production Subcutaneous tissue Squamous cells Sweat glands
Sebum production Explanation: Sebum production decreases with age, 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 244. Chapter 11: Skin, Hair, and Nails - Page 244
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? Skin warm and dry to the touch Small lesion left forearm for one month Denies any skin color changes Dry and flaky skin in the winter months
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails.
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? Stage I Stage II Stage III Stage IV
Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 263. Chapter 11: Skin, Hair, and Nails - Page 263
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? Stratum lucidum Stratum granulosum Stratum germinativum 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242
Which of the following findings related to hair would the nurse most likely assess in an older adult female client? Increased pubic hair Thick elastic scalp hair Terminal hair growth on chin Copper-red color
Terminal hair growth on chin Explanation: Older adult women may have terminal hair growth on the chin owing to hormonal changes. Hair in the older adult is typically thin and feels coarser and drier with aging. Pubic, axillary, and body hair also decrease with aging. Copper-red colored hair is found in African American children with severe malnutrition. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, pp. 242-243. Chapter 11: Skin, Hair, and Nails - Page 242-243
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 asthma The client has melanoma The client has COPD
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 261. Chapter 11: Skin, Hair, and Nails - Page 261
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? The client's current medication regimen The client's ability to change position The client's history of integumentary disorders The pigmentation of the client's skin
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 257. Chapter 11: Skin, Hair, and Nails - Page 257
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 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 The nurse can alleviate the client's fears about what caused the skin condition
The client's perception affects the approach and effectiveness in treating the skin condition Explanation: The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 253. Chapter 11: Skin, Hair, and Nails - Page 253
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? The elderly should only bathe or shower once a week The elderly should bathe or shower once every 2 weeks The elderly should bathe or shower daily but use lots of moisturizer The elderly should bathe or shower only every 2 to 3 days
The elderly should bathe or shower only every 2 to 3 days 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 244. Chapter 11: Skin, Hair, and Nails - Page 244
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? Multiple nevi Tinea corporis Herpes simplex Tinea versicolor
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 280. Chapter 11: Skin, Hair, and Nails - Page 280
A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? To determine the clients risk for pressure ulcers To determine the clients risk for skin cancer To determine the clients risk for herpes zoster To determine the clients risk for dehydration
To determine the clients risk for pressure ulcers Explanation: Older, disabled, or immobile clients who spend long periods of time in one position are at risk for pressure ulcers. Spending long periods of time sitting or lying in one position is not associated with increased risk for skin cancer, dehydration, or herpes zoster. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails.
What is the most important focus area for the integumentary system? UV radiation exposure Washing the face and hands Chemical exposure Moles with defined borders smaller than 6 mm
UV radiation exposure Explanation: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 250. Chapter 11: Skin, Hair, and Nails - Page 250
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? On the neck Upper abdomen Under the breast Anterior chest
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 255. Chapter 11: Skin, Hair, and Nails - Page 255
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? Urticaria or hives Insect bites Purpura Psoriasis
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 272. Chapter 11: Skin, Hair, and Nails - Page 272
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Wood's light Flashlight Sunlight Artificial light
Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 263. Chapter 11: Skin, Hair, and Nails - Page 263
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 hyperthyroidism. a great degree of cyanosis. a mild degree of cyanosis. lupus erythematosus.
a great degree of cyanosis. Explanation: 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 267. Chapter 11: Skin, Hair, and Nails - Page 267
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the soles of the feet. adipose tissue. areola of the breast. entire skin surface.
areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 244. Chapter 11: Skin, Hair, and Nails - Page 244
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 precancerous lesions. signs of dermatitis. signs of an infectious process. caused by aging of the skin in older adults.
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 262. Chapter 11: Skin, Hair, and Nails - Page 262
The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C? consistency color category characteristics
color Explanation: The C in the mnemonic ABCDE for evaluating a mole refers to the color of the mole. The A stands for asymmetrical; B stands for borders that are irregular; D stands for diameter exceeding 1/8 to 1/4 of an inch; and E stands for elevation. Category, consistency, and characteristics are not criteria when evaluating a mole. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 247. Chapter 11: Skin, Hair, and Nails - Page 247
Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. eccrine glands. keratinized tissue. dermis.
dermis. Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242
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 scales. fissures. ulcers. erosion.
fissures. Explanation: Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 274. Chapter 11: Skin, Hair, and Nails - Page 274
The nails, located on the distal phalanges of the fingers and toes, are composed of stratum cells. ectodermal cells. endodermal cells. keratinized epidermal 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242
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. patch. macule. 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 282. Chapter 11: Skin, Hair, and Nails - Page 282
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 arms. sclera. legs. abdomen.
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 255. Chapter 11: Skin, Hair, and Nails - Page 255
Connecting the skin to underlying structures is/are the subcutaneous tissue. sebaceous glands. dermis layer. papillae.
subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 11: Skin, Hair, and Nails, p. 242. Chapter 11: Skin, Hair, and Nails - Page 242