Chapter 11: Health Assessment Prep U
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin - A. - B12. - C. - D.
D
The nurse is preparing to examine a client's skin. What would the nurse do next? - Ensure that the room is hot to prevent chilling. - Wear gloves when preparing to inspect the skin and nails. - Expose only the body part that is being examined. - Have the client remove clothing from the upper body.
Expose only the body part that is being examined.
While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record? - Vascular - Purpuric - Primary - Secondary
Purpuric
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? - Small lesion left forearm for one month - Denies any skin color changes - Skin warm and dry to the touch - Dry and flaky skin in the winter months
Skin warm and dry to the touch
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
How should the nurse palpate the skin of a client to assess its texture? - Touch with the palmar surface of the three middle fingers. - Press the fingertips to the skin surface - Rub the dorsal surface of the hand over the skin - Pinch and roll the skin between the finger
Touch with the palmar surface of the three middle fingers.
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? - Sunlight - Artificial light - Wood's light - Flashlight
Wood's light
Connecting the skin to underlying structures is/are the - papillae. - sebaceous glands. - dermis layer. - subcutaneous tissue.
subcutaneous tissue.
The student nurse learns that examining the skin can do all of the following except? - Reveal overhydration - Allow early identification of neurologic deficits - Identify physical abuse - Allow early identification of potentially cancerous lesions
Allow early identification of neurologic deficits
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? - Alopecia areata - Trichotillomania - Tinea capitis - Traction alopecia
Alopecia areata
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 - Dermis - Epidermis
Dermis
A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the patient questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn? - The damage to keratin producing cells in the epidermis layer - Destruction of hair follicles located in the dermis layer - The impairment of apocrine gland to function effectively in the subcutaneous layer - The ability of the adipose layer to produce carotene has been destroyed
Destruction of hair follicles located in the dermis layer
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? - Diabetes mellitus - Psoriasis - Hypothyroidism - Contact dermatitis
Diabetes mellitus
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 smooth - Moist and rough - Dry and smooth - Dry and rough
Dry and rough
The apocrine glands are stimulated by what? - Emotional stress - Temperature - Physical stress - Overhydration
Emotional stress
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? - Impetigo - Psoriasis - Herpes zoster - Viral Exanthum
Impetigo
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 corneum - Stratum lucidum - Stratum granulosum - Stratum germinativum
Stratum corneum
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? - The client has a full-time caregiver. - The client is consistently incontinent of urine. - The client has a surgical diagnosis. - The client adheres to a vegetarian diet.
The client is consistently incontinent of urine.
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 - The nurse can alleviate the client's fears about what caused 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 cos
The client's perception affects the approach and effectiveness in treating the skin condition
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 mild degree of cyanosis. - lupus erythematosus. - hyperthyroidism.
a great degree of cyanosis.
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 - ineffective individual coping related to changes in appearance. - anxiety related to loss of outdoor activities and altered skin appearance. - dry flaking skin and dull dry hair as a result of disease. -risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.
risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.
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 - melanoma skin cancers are the most common type of cancers. - African Americans are the least susceptible to skin cancers. - usually there are precursor lesions for basal cell carcinomas. - squamous cell carcinomas are most common on body sites with heavy sun exposure.
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 - stage I. - stage II. - stage III. - stage IV.
stage II.
Local redness of the skin warns of impending necrosis. True False
true
Short, pale, and fine hair that is present over much of the body is termed - vellus. - dermal. - lanugo. - terminal.
vellus
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?" - "Does anyone else in your family have a rash like this?" - "Have you ever had a rash like this before?" - "What have you been doing to control the itching?"
"Are you allergic to foods, medications, or other substances?"
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? - "Has anyone in your family ever been diagnosed with skin cancer?" - "Have you ever been assessed for diabetes?" - "What dietary supplements do you usually take?" - "Do you take steroid medications on a regular basis?"
"Do you take steroid medications on a regular basis?"
A patient asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this patient's question? - "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." - "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." - "SPF 15 is the number of minutes that a person can safely stay in the sun after treating the skin with the product." - "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn."
"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. - pressure that impairs capillary blood flow to the skin - friction created by dragging the skin against bedlinen - shearing that occurs when sliding down in bed - moisture being allowed to accumulate on the skin - restlessly changing position frequently
- pressure that impairs capillary blood flow to the skin - friction created by dragging the skin against bedlinen - shearing that occurs when sliding down in bed - moisture being allowed to accumulate on the skin
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 - Parkinsons disease - Marfans syndrome - Cushings syndrome
Alcoholism
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 - Henna tattooing - Body piercing - Home remedy
Coining
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? - Iron deficiency anemia - Cushing's disease - Basal cell carcinoma - Lupus erythematosus
Cushing's disease
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 - Cushing's disease - Basal cell carcinoma - Lupus erythematosus
Cushing's disease
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? - Type - Color - Distribution - Arrangement
Distribution
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding? - Assess the client for changes in sensation due to vascular problems - Monitor the client for additional findings of cystic fibrosis - Suggest that the client use antiperspirant products - Document the findings in the client's record as normal
Document the findings in the client's record as normal
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? - Allow the client to pray before the examination - Let the client remained fully dressed for the examination - Have a nurse who is the same sex as the client examine him - Avoid asking any questions regarding the client's lifestyle
Have a nurse who is the same sex as the client examine him
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? - Small lesion left forearm for one month - Denies any skin color changes - Skin warm and dry to the touch - Dry and flaky skin in the winter months
Skin warm and dry to the touch
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? - Tenting indicates dehydration - Tenting indicates malnutrition - Tenting indicates dramatic weight loss - Tenting indicates vitamin B12 deficiency
Tenting indicates dehydration
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 bathe or shower only every 2 to 3 days - The elderly should only bathe or shower once a week - The elderly should bathe or shower daily but use lots of moisturizer - The elderly should bathe or shower once every 2 weeks
The elderly should bathe or shower only every 2 to 3 days
The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? - Vasoconstriction - Hyperglycemia - Hypoxemia - Cardiopulmonary insufficiency
Vasoconstriction
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? - Papule - Vesicle - Bulla - Crust
Vesicle
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? - Addison disease - Vitiligo - Tinea versicolor - Dermatomyositis
Vitiligo
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for - symptoms of stress. - recent radiation therapy. - pigmentation irregularities. - allergies to certain foods.
symptoms of stress
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? - "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."
"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."
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? - 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."
"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."
Which statement by a client about the skin needs validation by the collection of objective data by the nurse? - "I experience itchy and dry skin every winter" - "My feet hurt and are always cold to the touch" - "I had a small skin cancer removed about 3 years ago" - "My port wine birth mark has not gotten any bigger"
"My feet hurt and are always cold to the touch"
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. - Largest organ of the body - Involved in digestion of food - Protects against damage to the body from sunlight - Circulates blood throughout the body - Helps make vitamin D in the body - Aids in maintaining body temperature
- Largest organ of the body - Protects against damage to the body from sunlight - Helps make vitamin D in the body - Aids in maintaining body temperature
What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply. - the loss of skin turgor as a result of aging - a cancerous skin lesion located on the back - presence of a systemic disease like measles - a rash triggered by taking the medication ibuprofen - a reddened area on the heel that indicates a potential risk for pressure ulcer formation
- a cancerous skin lesion located on the back - presence of a systemic disease like measles - a rash triggered by taking the medication ibuprofen - a reddened area on the heel that indicates a potential risk for pressure ulcer formation
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. - intact, firm skin with redness - ulceration involving the dermis - full-thickness skin loss - necrosis with damage to underlying muscle
- intact, firm skin with redness - ulceration involving the dermis - full-thickness skin loss - necrosis with damage to underlying muscle
Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? - 9 or lower - 10 to 12 - 13 to 18 - 19 to 23
19 to 23
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? - 1 - 2 - 3 - 4
3
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? - Diabetes mellitus - Hypothyroidism - Crohns disease - Liver disease
Hypothyroidism
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? - Inspect the area - Ask further questions - Document the statement - Move on to next body system
Inspect the area
A client's fingernails are noted to be very thin and concave. The nurse knows the client needs medical follow-up for further assessment of which condition? - Diabetes mellitus - Iron deficiency anemia - Vitamin deficiency - Peripheral vascular disease
Iron deficiency anemia
Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? - It is likely to be related to her lupus. - It is likely to be related to an exposure to a chemical. - It is likely to be related to an allergic reaction. - It should not cause any problems.
It is likely to be related to her lupus.
Which of the following assessment findings most likely constitutes a secondary skin lesion? - Keloid formation at the site of an old incision - Facial acne - Facial lesions associated with herpes simplex - Psoriasis
Keloid formation at the site of an old incision
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? - Melasma generally resolves postpartum - Melasma is always permanent - Melasma can be treated with Betadine ointment - Melasma should be treated with antibiotics
Melasma generally resolves postpartum
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? - Nail beds - Sclera - Palms - Oral mucosa
Oral mucosa
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. What would the nurse do next? - Document the benign findings. - Perform a random blood sugar test. - Ask the client about a family history of cancer. - Refer the client for medical follow-up.
Perform a random blood sugar test.
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? - Reynaud disease - Central cyanosis - Neurofibromatosis - Peripheral cyanosis
Peripheral cyanosis
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
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? - Psoriasis, fungal infections, trauma - Vitiligo, hirsutism, vitamin deficiency - Eczema, melanoma, herpes zoster - Alopecia, dermatitis, chemotherapy
Psoriasis, fungal infections, trauma
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? - Eschar on an area near a bony prominence - Excessive sweating on a dependent body region - Skin that feels boggy on palpation - Loss of the dermis
Skin that feels boggy on palpation
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? - The client had a recent infestation - The client has had lice for quite some time - This is not lice; it is scabies - The nits indicate the infestation is over
The client had a recent infestation
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 melanoma - The client has COPD - The client has asthma
The client has chronic hypoxia
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 pigmentation of the client's skin - The client's history of integumentary disorders
The client's ability to change position
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 versicolor - Herpes simplex - Tinea corporis
Tinea corporis
What is the most important focus area for the integumentary system? - UV radiation exposure - Chemical exposure - Moles with defined borders smaller than 6 mm - Washing the face and hands
UV radiation exposure
Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese? - Anterior chest - Upper abdomen - On the neck - Under the breast
Under the breast
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? - Insect bites - Urticaria or hives - Psoriasis - Purpura
Urticaria or hives
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? - Vesicle - Papule - Wheal - Cyst
Vesicle
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 - blue. - red. - yellow. - purple
blue.
The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a - papule - wheal - pustule - bulla
papule
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. - macule. - papule. - patch.
papule
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? - heart sounds - bowel sounds - pulse oximetry - body temperature
pulse oximetry
A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by - scabies - lice - ticks - allergies
scabies
The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding? - Hypoxia - Recent trauma - Iron deficiency - Normal finding
Normal finding
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 - signs of an infectious process. - caused by aging of the skin in older adults. - precancerous lesions. - signs of dermatitis.
caused by aging of the skin in older adults.
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 Signs of an infectious process. Caused by aging of the skin in older adults. Precancerous lesions. Signs of dermatitis.
caused by aging of the skin in older adults.
Hair follicles, sebaceous glands, and sweat glands originate from the - epidermis. - eccrine glands. - keratinized tissue. - dermis.
dermis
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? - fainting - vomiting - diarrhea - diaphoresis
fainting
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 - mild - moderate - negligible
high
A patient with a zosteriform rash has a rash that - has lesions distributed over a large body area - appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion - is distributed along a dermatome - is distributed equally on both sides of the body
is distributed along a dermatome
The nails, located on the distal phalanges of the fingers and toes, are composed of - ectodermal cells. - endodermal cells. - keratinized epidermal cells. - stratum cells.
keratinized epidermal cells.
A decrease in oxyhemoglobin will result in documentation of pallor. True False
True
