Chapter 14: Assessing Skin, Hair, and Nails Combined (Final)

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

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

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

Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.

Disturbed Body Image Ineffective Individual Coping Anxiety Explanation: This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection.

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.

Explanation: The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking Explanation: An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.

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 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.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

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

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 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.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

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.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

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.

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. Explanation: Blue-green fluorescence indicates fungal infection.

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

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.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting Explanation: Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia. Explanation: Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia.

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. Explanation: Plaques are elevated, palpable, solid masses greater than 0.5 cm and may be coalesced papules with a flat top. Papules are also elevated, palpable, sold masses, but are smaller than 0.5 cm. Macules and patches are small, flat, nonpalpable skin color changes.

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?

pulse oximetry Explanation: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

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

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

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

squamous cell carcinomas are most common on body sites with heavy sun exposure. Explanation: Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

Connecting the skin to underlying structures is/are the

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

To assess an adult client's skin turgor, the nurse should

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

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

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

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch" Explanation: A nurse needs to validate any subjective information that either does not fit with the rest of the information supplied by the client or any information that may indicate a problem exists. Cold feet that are painful need to be validated by careful assessment of the client's circulation. Dry and itchy skin is expected in the winter when the air is dry. Previous history of cancer and a port wine spot are past of the past medical history.

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

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?

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.

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years Explanation: The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red hair. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.

A client is diagnosed with a stage I pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

Palmar surfaces Explanation: The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.

A client has a small but elevated, solid, palpable, 0.5 cm mass on the forearm. Which diagram should the nurse use to explain this mass to the client?

A plaque is an elevated, palpable, and solid mass that is greater than 0.5 cm and may be coalesced papules with a flat top. A tumor is an elevated, solid, palpable mass that extends deeper into dermis than a papule. Tumors are greater than 1-2 cm and do not always have sharp borders. A wheal is an elevated mass with transient borders that is often irregular. A vesicle is a circumscribed elevated, palpable mass containing serous fluid that is less than 0.5 cm.

The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash?

Allergic reaction Explanation: Contact dermatitis occurs as an inflammatory response to an antigen. Contact dermatitis is not caused by low fluid volume, high blood pressure, or an insufficient intake of protein.

The student nurse learns that examining the skin can do all of the following except?

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.

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

Assists in friction protection Explanation: Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

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 "ABCDE" characteristic of malignant melanoma?

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 to 1/4 of an inch, and E for elevated.

Recommended protective measures to avoid skin cancer include which of the following?

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

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.

The nurse should use which assessment tool to assess the client's risk for skin breakdown?

Braden Scale Explanation: The Braden Scale or Norton Scale, or another skin assessment tool should be used to assess for skin breakdown risk factors according to hospital standard protocol. The Hendrick II and Morse scale assess fall risk. Upon admission, clients are evaluated for venous thromboembolism (VTE) risk; but a separate skin assessment tool is used as well.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale Explanation: Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

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

Which clinical manifestation should the nurse expect to find in a client with edema?

Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.

A client is diagnosed with paronychia. Which part of the diagram should the nurse assess for this health problem?

Paronychia is an infection of the cuticle. That is the area on the diagram that is affected.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

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.

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 Explanation: Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Cushing disease can result in female facial hair growth.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D. Explanation: The skin is the largest organ of the body. It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

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?

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.

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

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.

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?

Document the findings in the client's record as normal Explanation: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating.

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?

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.

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

Existence of systemic diseases that have skin manifestations Explanation: One purpose of the integumentary health history is to identify systemic diseases that have skin manifestations. Questions to determine systemic diseases that the client may have include asking about prescribed medications, immunizations, and diagnosed illnesses. Such a history would provide little information regarding health promotion care, or risks for skin cancer or skin ulcer formation.

A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Explanation: A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A client is diagnosed with a stage IV pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Explanation: A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.

Explanation: Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs.

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

Fluid-filled lesions less than 1 cm in diameter Explanation: The rash of chicken pox is vesicles that are fluid-filled and less than 1 cm in diameter.

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?

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

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

The RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed Explanation: Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.

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 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.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

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

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply.

Lymphatic vessels Blood vessels Sweat glands Explanation: The dermis is the layer of skin below the epidermis. The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, blood vessels, lymph vessels, and nerve endings. It is also the origin of sebaceous glands, sweat glands, and hair follicles. Fat cells are contained in the subcutaneous tissue. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects the infant's skin.

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 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.

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm. Explanation: To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the client's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position or is dragged rather than lifted up from a supine position, for example, the movements may distort the soft tissues of the buttocks and close off the arteries and arterioles. Friction and moisture further increase the risk. Changing position frequently will assist in preventing pressure sores.

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis Explanation: Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

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

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution Explanation: This is the correct description for the mnemonic.

While assessing a client'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?

Purpuric Explanation: Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

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

When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)

Red or light hair Freckles Immunosuppression Explanation: Risk factors for melanoma: history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sun exposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?

Signs and symptoms of melanoma Explanation: A simple method is to use the ABCDEs of melanoma detection: Asymmetry, Border irregularity, Color, Diameter of more than 6 mm, Evolution of lesion over time. The other given options are correct, but the most appropriate response is teaching about melanoma.

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

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails Explanation: Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial Explanation: A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The client exhibits no signs or symptoms of infection Explanation: All options are appropriate outcomes for this client, but the most important outcome is that the client exhibits no signs or symptoms of infection since infection is a risk for additional injury.

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 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.

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?

The client may have been abused. Explanation: Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold. 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 response to anxiety or a cold environment. The bluish color of a subcutaneous vein is not the trigger for this form of cyanosis.

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?

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.

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 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.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers. Explanation: The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.

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?

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.

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 Explanation: The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal Explanation: A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. An erosion is a loss of superficial epidermis that does not extend to the dermis.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness. Explanation: Beau's lines occur after acute illness and eventually grow out.

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease Explanation: Central cyanosis is a bluish-tint to the lips, tongue, and oral mucosa. Causes of central cyanosis include advanced lung disease. Pallor is associated with anemia. Jaundice is associated with liver disease. Cyanosis in congestive heart failure is usually peripheral, reflecting decreased blood flow.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

ashen. Explanation: Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

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. Explanation: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C?

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.

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. 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.

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 Explanation: This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism. Explanation: Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

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. Explanation: Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

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

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules. Explanation: Freckles are flat, small macules of pigment that appear following sun exposure.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma. Explanation: Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa. Explanation: Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage II. Explanation: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

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. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries Explanation: Oxyhemoglobin, a bright red pigment, predominates in the arteries and capillaries. An increase in blood flow through the arteries to the capillaries causes a reddening of the skin (e.g., with blushing), whereas the opposite change usually produces pallor. Hemoglobin circulates in the red cells and carries most of the oxygen of the blood. An increased concentration of deoxyhemoglobin in cutaneous blood vessels gives the skin a bluish cast known as cyanosis. The loss of blood from the circulatory results in hemorrhage and hypotension.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

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