Chapter 11- Skin, Hair, and Nails
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?
cushing's disease
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
fissures
the nurse is admitting a 79-year-old man for outpatient surgery. the client has bruises in various stages of healing all over his body. why is it important for the nurse to promptly document and report these findings?
he may have been abused
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?
hypothyroidism
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
a client tells the clinic nurse that his feet and lower legs turn a blue color. on assessment, the nurse notes that the client's oxygenation level is within normal levels. the nurse knows that the blue color the client described is caused by what?
peripheral cyanosis
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 II
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 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?"
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?
"having bad sunburns when you're a child puts you at risk for skin cancer later in life."
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
15
the skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
D
the apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast
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
caused by aging of the skin in older adults