Chapter 24: Assessment of the Skin, Hair, and Nails

8. A nurse assesses a client who has open lesions. Which action should the nurse take first? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the clients pain. d. Obtain vital signs.

ANS: A Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.

5. A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles

ANS: A Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.

12. A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

ANS: A Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper- thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

2. A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. What do you do for a living? b. Are your nails professionally manicured? c. Do you have diabetes mellitus? d. Have you had a recent fungal infection?

ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

9. A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder? a. Clean hair and nails b. Poor eye contact c. Disheveled appearanced. d. Drapes a scarf over the face

ANS: A The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails; good eye contact; and being socially active. A disheveled appearance and draping a scarf over the face to hide the clients appearance demonstrate that the client may be having difficulty coping with his or her condition.

3. A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion. c. Examine the distribution of lesions over a section of the body. d. Monitor for edema or swelling of tissues. e. Focus your assessment on skin areas that itch.

ANS: A, B Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

2. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results

ANS: A, C, D Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the clients nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

11. During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

ANS: B Diffuse is used to describe lesions that are widespread. Serpiginous describes lesions with wavy borders. Clustered describes lesions grouped together. Linear describes lesions occurring in a straight line. Annular lesions are ringlike with raised borders, circinate lesions are circular, and circumscribed lesions have well- defined sharp borders. Coalesced describes lesions that merge with one another and appear confluent.

6. While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the clients pedal pulses bilaterally. c. Check for the presence of Homans sign. d. Assess the clients skin for adequate skin turgor

ANS: B Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the clients limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow.

10. A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: B Pallor conjunctivae signifies anemia. The nurse should assess the clients hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this clients potential anemia.

1. While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. a. Ask the client about current medications he or she is taking. b. Use pulse ox to assess the clients o2 sat c. Auscultate the clients lung field for adventitious sounds d. Palpate the clients bilateral radial and pedal pulses

ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments. DIF: Applying/Application REF: 438KEY: CyanosisMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? a. I will consult the chaplain to provide you with spiritual support. b. You do not need to go to church; God is everywhere. c. Tell me more about your concerns related to your skin. d. Religious people are nonjudgmental and will accept you.

ANS: C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the clients skin changes are affecting the clients body image and encourage the client to express his or her feelings about a change in appearance. The other responses are not appropriate.

4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? a. This rash is probably due to fluid overload. b. I need to wash this daily with antibacterial soap. c. I can use powder to keep this area dry. d. I will schedule a mammogram as soon as I can.

ANS: C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. Are you using lotion on your skin? b. Do you have a family history of this? c. Do your arms itch? d. What medications are you taking?

ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

1. A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Societys hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.