Chapter 14: Assessing Skin, Hair, and Nails

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse? "I understand your concern, but this is a normal part of aging." "It sounds like you may have developed a deep vein thrombosis." "Have you ever told your health care provider this?" "It sounds like you have developed peripheral neuropathy."

"It sounds like you have developed peripheral neuropathy." Chapter 14: Assessing Skin, Hair, and Nails - Page 250

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized? A neuropathic ulcer can develop without feeling it. Skin collagen decreases with age. Wound healing becomes prolonged with age. Hydration alters skin turgor.

A neuropathic ulcer can develop without feeling it.

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

Acne Chapter 14: Assessing Skin, Hair, and Nails - Page 274

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 keeping the skin intact Assists in friction protection Assists in protection from infection Assists in keeping skin dry

Assists in friction protection Chapter 14: Assessing Skin, Hair, and Nails - Page 249

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. Asymmetrical Flat Change in size Itching Bleeding of a mole Regular borders

Asymmetrical Change in size Itching Bleeding of a mole Chapter 14: Assessing Skin, Hair, and Nails - Page 276

The nurse should use which assessment tool to assess the client's risk for skin breakdown? Braden Scale Hendrich II Morse Scale VTE prophylaxis algorithm

Braden Scale Chapter 14: Assessing Skin, Hair, and Nails - Page 257

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister

Broken with the presence of a blister Chapter 14: Assessing Skin, Hair, and Nails - Page 274

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

Carotene Chapter 14: Assessing Skin, Hair, and Nails - Page 260

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin A. B12. C. D.

D. Chapter 14: Assessing Skin, Hair, and Nails - Page 247

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

Dermis Chapter 14: Assessing Skin, Hair, and Nails - Page 248

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take? Notify the health care provider. Inform the client to stop chemotherapy. Document findings. Suggest the client shave their head.Document findings.

Document findings. Chapter 14: Assessing Skin, Hair, and Nails - Page 251

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? Around the mouth and lips Chest and abdomen Fingers and toes Nose and earlobes

Fingers and toes Chapter 14: Assessing Skin, Hair, and Nails - Page 260

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. Chapter 14: Assessing Skin, Hair, and Nails - Page 259

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 Cushing disease

Hypothyroidism Chapter 14: Assessing Skin, Hair, and Nails - Page 251

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 259

The nurse is providing discharge teaching to a client who underwent a hip fracture repair. The nurse should instruct the client to report which findings that indicate surgical site infection? (Select all that apply.) Pain at incision site Tenderness at incision site Redness over hip area Diffuse hives over body Surgical site warm to touch

Pain at incision site Tenderness at incision site Redness over hip area Surgical site warm to touch Chapter 14: Assessing Skin, Hair, and Nails - Page 276

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Limbs Vertex Eyebrows Palmar surfaces

Palmar surfaces Chapter 14: Assessing Skin, Hair, and Nails - Page 249

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 259

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.

Subcutaneous Tissue Chapter 14: Assessing Skin, Hair, and Nails - Page 249

Which of the following is an important function of the skin? Synthesis of vitamin D Production of carotene Maintenance of acid-base balance Protection against melanin deposits

Synthesis of vitamin D Chapter 14: Assessing Skin, Hair, and Nails - Page 247

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. The client is elderly. The client may have peripheral vascular disease. The client may have a cognitive deficit.

The client may have been abused. Chapter 14: Assessing Skin, Hair, and Nails - Page 275

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 cost

The client's perception affects the approach and effectiveness in treating the skin condition Chapter 14: Assessing Skin, Hair, and Nails - Page 251

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 277

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 247

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 262

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 273

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. Chapter 14: Assessing Skin, Hair, and Nails - Page 260

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

ashen. Chapter 14: Assessing Skin, Hair, and Nails - Page 260

Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. eccrine glands. keratinized tissue. dermis.

dermis. Chapter 14: Assessing Skin, Hair, and Nails - Page 248

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

fainting Chapter 14: Assessing Skin, Hair, and Nails - Page 260

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 269

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. hyperthyroidism. infectious conditions. hypoparathyroidism.

hypothyroidism. Chapter 14: Assessing Skin, Hair, and Nails - Page 251

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions? iron deficiency anemia fungal infection psoriasis hypoxia

hypoxia Chapter 14: Assessing Skin, Hair, and Nails - Page 266

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client? normal age-related changes in hair growth increased facial hair growth premature graying of hair patchy, thin hair

patchy, thin hair Chapter 14: Assessing Skin, Hair, and Nails - Page 251

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 Chapter 14: Assessing Skin, Hair, and Nails - Page 266

To assess an adult client's skin turgor, the nurse should press down on the skin of the feet. use the dorsal surfaces of the hands on the client's arms. use the finger pads to palpate the skin at the sternum. use two fingers to pinch the skin under the clavicle

use two fingers to pinch the skin under the clavicle Chapter 14: Assessing Skin, Hair, and Nails - Page 264