Chapter 14: Assessing Skin, Hair, and Nails

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 (skin cancer increases w/ sun exposure, male gender, and advancing age)

A nurse cares for a pt. w/ stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken w/ presence of blister

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?

Clustered (ex. of annular- tinea corporis; ex. of discrete-- multiple nevi)

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated w/ which disease process?

Cushings disease (Hirsutism-- facial hair on females; is a characteristic of cushings disease and results from imbalances of adrenal hormones)

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

Decreased skin mobility (assessed by gently pinching skin on sternum or under clavicle using two fingers and determine how easily skin can be pinched)

A nurse is working w/ 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 the sweat comes from. The nurse knows that sweat glands are located in which layer of the skin?

Dermis

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 w/ this rash!" Which nursing diagnosis can the nurse confirm w/ this data?

Disturbed body image, ineffective individual coping, and anxiety

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

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 skin to detect the presence of this condition?

Fingers and toes (changes in color around mouth are called circumoral; bluish tints to chest and abdomen is central cyanosis)

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

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 from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

Which technique should the nurse use to properly assess a client's skin turgor?

Pinch the skin over the clavicle and observe its return to the original shape

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 (also inspect skin on the limbs and groin area)

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement?

Use sunlight if possible to inspect the skin, have the client remove his toupee, wear gloves when palpating lesions, keep the room door closed

A 5 year old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

Melanin

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?

Nail problems can be caused by an underlying systemic illness

A client reports feeling SOB. Which area of the body should the nurse inspect for cyanosis?

Perioral (cyanosis makes white skin appear blue-tinged esp. in perioral, nailbed, and conjunctival areas)

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

A nurse implements which skin assessment to determine the presence of dehydration in a client?

Turgor (in dehydration skin turgor is decreased)

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

Woods light (shows a blue-green fluorescence if lesion is due to fungal infection)

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"

During the physical assessment of a client w/ dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

Document this as a normal finding

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 (increase in angle seen in clients w/ clubbing which occurs from hypoxia secondary to cigarette smoking; exposure to chemicals can cause nails to be excessively dry or to have splinter hemorrhages due to trauma)

A client presents to the health care clinic w/ reports of new onset of generalized hair loss for the past 2 months. The client denies the use of new shampoos or other hair care products and claims not to be takin any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?

Largest organ of the body, protects against damage to the body from sunlight, helps make vitamin D in the body, aids in maintaining body temp

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule (nonpalpable, may be brown, white, tan, red, or purple; ex. freckles and port wine birthmarks)

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that it has become difficult to cut the toenails bc the nails have become brittle and hard. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?

Risk for impaired skin integrity (bc presence of thickened toenails may cause damage to epidermis of skin on lower extremities)

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective w/ regards to the skin?

Skin warm and dry to the touch

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

Spooning (clubbing evident in O2 deficieny; Beaus lines occur after acute illness and grow out; Paronychia is infection of the nail bed)

A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective info to assist in reassessment 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 client's risk for pressure ulcers

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 (irregular borders, color variations, diameter exceeding 1/8 to 1/4 of an inch and elevated)

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 a danger signs associated w/ skin lesions indicating this disease?

Asymmetrical, change in size, itching, bleeding of a mole

A 4 year old child presents to health care clinic w/ circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis (ex. of confluent-- tinea versicolor)

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

Touch w/ the palmar surface of the three middle fingers (most sensitive to texture; palmar and dorsal surfaces of hand used to assess temperature; dorsal or palmar surfaces of the hands and fingers detect moisture on skin; fingertips not used to palpate skin)

Upon examination of a pt., the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

Vesicle