Chapter 12: Skin, Hair, and Nails

The nurse needs to be familiar with the various lesions that may be identified on assessment of the skin. Match each description given below with the appropriate term. 1.Tiny punctate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color 2.A large patch of capillary bleeding into tissues 3.A hypertrophic scar 4.Elevated cavity containing free fluid, up to 1 cm. Clear serum flows if wall is ruptured. 5.Also known as a friction blister 6.Solid, elevated, hard or soft, larger than 1 cm

1. Bulla 2. Petechiae 3. Nodule 4. Keloid 5. Vesicle 6. Ecchymosis (bruise) ASN: 2,6,4,5,1,3

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: 1.polycythemia. 2.carbon monoxide poisoning. 3.carotenemia. 4.uremia.

ANS: 2 A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she has noticed it for several months and it has slowly grown larger. The nurse suspects which condition? 1.Acne 2.Basal cell carcinoma 3.Malignant melanoma 4.Squamous cell carcinoma

ANS: 2 Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer, and it grows slowly.

A 22-year-old-woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to the medication she is taking for: 1.pain. 2.acne. 3.heartburn. 4.hyperthyroidism.

ANS: 2 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

The nurse is assessing the skin of a patient who has AIDS and notices a widely disseminated, violet-colored tumor covering the skin and mucous membranes. The nurse would conclude that: 1.he is in the first stage of AIDS. 2.he is in the advanced stage of AIDS. 3.this person has been exposed to a viral infection. 4.these lesions indicate an advanced case of herpes zoster.

ANS: 2 In the advanced stage of AIDS, you may notice widely disseminated lesions involving the skin, mucous membranes, and visceral organs.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown in color. However, the skin on the hard/soft palate is a pink in color. From this finding, the nurse could probably rule out: 1.pallor. 2.jaundice. 3.cyanosis. 4.iron deficiency.

ANS: 2 Jaundice is exhibited by a yellow color, indicating rising amounts of bilirubin in the blood and is first noticed in the junction of the hard and soft palate in the mouth and in the sclera.

A patient has tingling sensations in her feet and has noticed that her tongue has become very red and painful. The nurse suspects that she has: 1.polycythemia. 2.pernicious anemia. 3.micronucleus anemia. 4.iron deficiency anemia.

ANS: 2 Pernicious anemia is indicated by neurologic deficits and a red, painful tongue along with a lemon yellow tint of the face and slightly yellow sclera.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would would: 1.tell the patient to watch the lesion and report back in 2 months. 2.refer the patient because of the suspicion of melanoma on the basis of her symptoms. 3.ask additional questions regarding environmental irritants that may have caused this condition. 4.suspect that this is a compound nevus, which is very common in young to middle- aged adults.

ANS: 2 The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant referral.

A thorough skin assessment is very important because the skin holds information about: 1.support systems. 2.circulatory status. 3.socioeconomic status. 4.psychological wellness.

ANS: 2 The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

A 13-year old girl is interested in obtaining information about the cause of her acne. The nurse would share with her that acne is: 1.contagious. 2.caused by a poor diet. 3.found in about 70% of all teens. 4.has been found to be related to poor hygiene.

ANS: 3 About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, or contagion.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: 1.keratosis. 2.mitoasma. 3.linea nigra. 4.linea gravida.

ANS: 3 In pregnancy, skin changes can include striae, linea nigra, chloasma (brown patches of hyperpigmentation), and vascular spiders.

When assessing inflammation in a dark-skinned person, the nurse may need to: 1.assess the skin for cyanosis and swelling. 2.assess the oral mucosa for generalized erythema. 3.palpate the skin for edema and increased warmth. 4.palpate for tenderness and local areas of ecchymosis.

ANS: 3 Inflammation is not easily recognized, and it is often necessary to palpate the skin for increased warmth, taut surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.

An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of the following is true about the Inuit sweating tendencies? 1.They will sweat profusely all over their bodies because they are not used to the hot temperatures. 2.They don't sweat because their diet is so high in roughage that their apocrine glands are less efficient in hot climates. 3.They will sweat more on their faces because this is an adaptation that has been made over time for survival in their environment. 4.They have an overabundance of eccrine sweat glands and so the nurse might expect them to have body odor because of the bacterial flora reacting with the apocrine sweat.

ANS: 3 Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find: 1.pallor. 2.coolness. 3.distended veins. 4.decreased capillary filling time.

ANS: 3 Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth and distended veins. See Table 12-1.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her: 1."They are signs of decreased hematocrit related to anemia." 2."They are due to destruction of melanin in your skin from exposure to the sun." 3."They are clusters of melanocytes that appear after extensive sun exposure." 4."They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

ANS: 3 Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin? 1.Ruddy blue 2.Generalized pallor 3.Ashen, gray, or dull 4.Patchy areas of pallor

ANS: 3 Pallor in black-skinned people will appear ashen, gray, or dull. See Table 12-2.

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of the following? 1.Subcutaneous fat deposits are high in the newborn 2.Sebaceous glands are over productive in the newborn 3.The newborn's skin is more permeable than that of the adult 4.The amount of vernix caseosa rises dramatically in the newborn

ANS: 3 The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: 1.caused by an excess of melanin pigment. 2.caused by an excess of apocrine glands in her feet. 3.caused by the complete absence of melanin pigment. 4.related to impetigo and that it can be treated with an ointment.

ANS: 3 Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: 1.bulla. 2.wheal. 3.nodule. 4.papule.

ANS: 4 A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm diameter, and is due to superficial thickening in the epidermis.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to: 1.increased vascularity of the skin in the elderly. 2.increased numbers of sweat and sebaceous glands in the elderly. 3.an increase in elastin and a decrease in subcutaneous fat in the elderly. 4.an increased loss of elastin and a decrease in subcutaneous fat in the elderly.

ANS: 4 An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following: 1.anasarca. 2.scleroderma. 3.pedal erythema. 4.clubbing of the nails.

ANS: 4 Clubbing of the nails occurs with congenital, chronic, cyanotic heart disease and with emphysema and chronic bronchitis.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this is because of a decrease in the number of functioning: 1.metrocytes. 2.fungacytes. 3.phagocytes. 4.melanocytes.

ANS: 4 In the aging hair matrix, the number of functioning melanocytes decreases so the hair looks gray or white and feels thin and fine.

A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find: 1.a keloid. 2.a fissure. 3.keratosis. 4.lichenification.

ANS: 4 Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules.

Which of the following assessment findings is most consistent with clubbing of the fingernails? 1.A nail base that is firm to palpation and slightly tender 2.Curved nails with a convex profile and ridges across the nail 3.A nail base that feels spongy with an angle of the nail base of 150 degrees 4.An angle of the nail base of 180 degrees or greater with a nail base that feels spongy

ANS: 4 The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

The nurse notices that a patient has bluish-white, red-based spots in her mouth that are elevated about 1 mm to 3 mm. What other signs would the nurse expect to find in this patient? 1.A pink, papular rash on the face and neck 2.Pruritic vesicles over her trunk and neck 3.Hyperpigmentation on the chest, abdomen, and the back of the arms 4.A red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: 4 With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. Koplik's spots in the mouth would also be found.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with her scissors because: 1.the woman could be at increased risk for infection and lesions because of her chronic disease. 2.with her diabetes, she has increased circulation to her foot and it could cause severe bleeding. 3.she is 75 years old and is unable to see, so she puts herself at greater risk for self- injury with the scissors. 4.with her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: 1 A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles.

A patient tells the nurse that he has noticed that one of his nevi has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? 1.Color variation 2.Border regularity 3.Symmetry of lesions 4.Diameter less than 6 mm

ANS: 1 Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notes the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema? 1.Heart failure 2.Venous thrombosis 3.A local inflammation 4.Blockage of lymphatic drainage

ANS: 1 Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to: 1.the eccrine glands. 2.the apocrine glands. 3.a disorder of the stratum corneum. 4.a disorder of the stratum germinativum.

ANS: 1 The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are located mainly in the axillae, anogenital area, nipples, and naval and mix with bacterial flora to produce characteristic musky body odor.

The nurse is caring for a black child who has been diagnosed with marasmus. The nurse would expect to find: 1.the hair to be less kinky and to be a copper-red color. 2.the head to be larger than normal, with wide-set eyes. 3.the skin on the hands and feet to be scaly and tender. 4.the lymph nodes in the groin to be enlarged and tender.

ANS: 1 The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting: 1.tinea capitis. 2.tinea corporis. 3.toxic alopecia. 4.seborrheic dermatitis.

ANS: 1 Tinea capitis is rounded patchy hair loss on scale, leaving broken-off hairs, pustules, and scales on the skin. It is due to fungal infection. Lesions are fluorescent under a Wood's light. It is usually seen in children and farmers and is highly contagious.

During an examination, the nurse finds that a patient has excess dryness of the skin. The best term to describe this condition is: 1.xerosis. 2.pruritus. 3.scoliosis. 4.seborritus.

ANS: 1 Xerosis is the term used to describe skin that is excessively dry.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: 1.rubeola. 2.Lyme disease. 3.allergy to mosquito bites. 4.Rocky Mountain spotted fever.

ANS: 2 Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or popular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy.

Jaundice is exhibited by a yellow skin color, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice? 1.Yellow patches throughout the sclera 2.Yellow color of the sclera that extends up to the iris 3.Skin that appears yellow when examined under low light 4.Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: 2 The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice.

A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: 1.venous pooling. 2.peripheral vasodilation. 3.peripheral vasoconstriction. 4.decreased arterial perfusion.

ANS: 3 A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. See Table 12-1.

A 32-year-old female patient complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: 1.anascara. 2.scleroderma. 3.senile angiomas. 4.latent myeloma.

ANS: 3 Cherry (senile) angiomas are small, punctate, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old.

40. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions? 1.Cases of severe obesity 2.During childhood growth spurts 3.In an individual who is severely dehydrated 4.With conditions of connective tissue disorders such as scleroderma

ANS: 3 Decreased skin turgor is associated with severe dehydration, aging, or extreme weight loss.

The nurse is discussing epidermal appendages with a patient. Which of the following would be included in the discussion? 1.Skin 2.Arms 3.Sweat glands 4.Parotid glands

ANS: 3 Epidermal appendages include hair, sebaceous glands, sweat glands, and nails.

Because hair for humans is no longer needed for protection from cold or trauma, it is called: 1.vellus. 2.vagus. 3.vestigial. 4.vestibule.

ANS: 3 Hair is vestigial for humans. It no longer is needed for protection from cold or trauma.

A patient has been admitted for severe iron deficiency anemia. The nurse can expect to see what finding in the patient's fingernails? 1.Splinter hemorrhages 2.Paronchyia 3.Koilonychia (spoon nails) 4.Beau's lines

ANS: 3 Koilonychia, or spoon nails, are thin, depressed nails with lateral edges tilted up, forming a concave profile. If all nails involved, they may be due to iron deficiency anemia.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say: 1."He is referring to that blue dilation of blood vessels in a star-shaped linear pattern on the legs." 2."He is referring to that fiery red, star-shaped marking on the cheek that has a solid circular center." 3."He is referring to that confluent and extensive patch of petechiae and ecchymoses on the feet." 4."He is referring to those tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: 3 Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following? 1.An increased possibility of bruising 2.Skin sensitivity as a result of exposure to salt water 3.Lack of availability of glucose monitoring supplies 4.The importance of sunscreen and avoiding direct sunlight

ANS: 4 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands this condition to be due to hyperemia and knows that it can be caused by: 1.decreased amounts of bilirubin in the blood. 2.excess blood in the underlying blood vessels. 3.decreased perfusion to the surrounding tissues. 4.excess blood in the dilated superficial capillaries.

ANS: 4 Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cooler examination room temperature. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: 1.café au lait. 2.carotenemia. 3.acrocyanosis. 4.cutis marmorata.

ANS: 4 Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity and is a transient mottling in the trunk and extremities in response to cooler room temperatures.

A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? 1.He probably has senile lentigines, which do not become cancerous. 2.He probably has actinic keratoses, a precursor to basal cell carcinoma. 3.He probably has acrochordons, precursors to squamous cell carcinoma. 4.He probably has seborrheic keratoses, which do not become cancerous.

ANS: 4 Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on the trunk. These lesions do not become cancerous.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant? 1.Over the sternum 2.Over the forehead 3.Over the forearms 4.Over the abdomen

ANS: 4 Test mobility and turgor over the abdomen in an infant. Poor turgor, or "tenting," indicates dehydration or malnutrition.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of the following would be included in the module? 1.The dermis contains mostly fat cells. 2.The dermis consists mostly of keratin. 3.The dermis is replaced every 4 weeks. 4.The dermis contains sensory receptors

ANS: 4 The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, contains nerves, sensory receptors, blood vessels, and lymphatics.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of the following would be included in the module? 1.The epidermis is very vascular. 2.The epidermis is thick and tough. 3.The epidermis is thin and non-stratified. 4.The epidermis is replaced every 4 weeks.

ANS: 4 The epidermis is thin, replaced every 4 weeks, avascular, and stratified into several zones.

A mother brings her child in to the clinic for an examination of the scalp and hair. She states that the child has developed some places where there are irregularly shaped patches with broken-off, stub-like hair and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is: 1.folliculitis and that it can be treated with an antibiotic. 2.traumatic alopecia that can be treated with antifungal medications. 3.tinea capitis and that it is highly contagious and needs immediate attention. 4.trichotillomania and that her child probably has a habit of twirling her hair absent- mindedly.

ANS: 4 Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly- shaped patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It occurs as a child rubs or twirls the area absently while falling asleep, reading, or watching television.

The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find: 1.lesions that run together. 2.annular lesions that have grown together. 3.lesions arranged in a line along a nerve route. 4.lesions that are grouped or clustered together.

ANS:1 Grouped lesions are clustered together. Polycyclic lesions are annular in nature. Zosteriform lesions are arranged along a nerve route. Confluent lesions run together.

A patient's mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: 1.eczema. 2.impetigo. 3.herpes zoster. 4.diaper dermatitis.

ANS:2 Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children.