Chapter 60 assessment of integumentary function
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? Bright red moles Liver spots Dark discoloration of the skin Yellowish waxy deposits on the eyelids
Yellowish waxy deposits on the eyelids Explanation: Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia. Solar lentigo refers to liver spots. Melasma refers to dark discoloration of the skin. Cherry angioma is the term used to describe a bright red mole.
The purpose of melanin is to: determine skin color. form a callus where the skin is subjected to friction. prevent drying and cracking of the skin and hair. assist in transfer of heat through contact.
determine skin color. Explanation: The color of the skin is determined by a pigment called melanin, which is manufactured by melanocytes located in the epidermis. A callus is a thick layer of epidermal cells that forms in response to recurring friction on an area of skin. Conduction is the transfer of heat through contact. Sebum prevents drying and cracking of the skin and hair.
A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. Skin Endocrine glands Subcutaneous tissue Hair Fingernails
Fingernails Hair Skin Explanation: Nails are layers of hard keratin that have a protective function. The epidermis contains an outer layer of dead skin that forms a tough protective protein called keratin. Hundreds of strands of keratin link together with amino acids to form hair. Endocrine glands and subcutaneous tissue are not made of keratin.
After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? Freckles Yellowish waxy deposits Itchy spots Dryness
Freckles Explanation: Lentigines are freckles. Xerosis is dryness. Neurodermatitis is itchy spots. Xanthelasma is the yellowish waxy deposits on the upper and lower eyelids
When assessing pallor, the nurse understands that it is best observed on which of the following areas? Nail beds Ear lobes Bony prominences Conjunctivae
Conjunctivae Explanation: Pallor is the absence of or a decrease in normal skin color and vascularity and is best observed in the conjunctivae or around the mouth.
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Epidermis Dermis Stratum corneum Papillary layer
Dermis Explanation: The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lies directly beneath the epidermis.
The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? Fungal infection Seborrheic dermatosis Psoriasis Herpes zoster
Herpes zoster Explanation: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined.
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? Protect the patient from the light. Obtain samples of the lesion by scraping. Make sure that the room is darkened. Apply a special dye to the area.
Make sure that the room is darkened. Explanation: When performing a Wood's light examination, the nurse would need to ensure that the room is darkened to allow visualization of the fluorescent light so that he or she can differentiate epidermal from dermal lesions. Dye is used for immunofluorescence. There is no need to protect the patient from the light. Skin scrapings involve obtaining samples of the lesion.
The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding? Sparse hair, white in color Dry, brittle hair Knots in hair when brushed Pearly white substance that is attached to the hair shaft that is not removed with brushing
Pearly white substance that is attached to the hair shaft that is not removed with brushing Explanation: The pearly white substance that is attached to the hair shaft is indicative of nits or head lice and should be reported to the physician so treatment can be administered. The other findings are not abnormal in the older adult client.
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? Telangiectasias Petechiae Ecchymoses Cherry angiomas
Petechiae Explanation: Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.
The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? Psoriasis Vitiligo Melanoma Petechia
Psoriasis Explanation: Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.
The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted? White patches Blue-green hue Purple-gray cast Red coloration
Purple-gray cast Explanation: Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. Inflammation in light-skinned people is noted by erythema, or redness of the skin.
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Crust Scale Scar Ulcer
Scale Explanation: A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.
The nurse is caring for a client with herpes zoster. The nurse documents the lesions as wheals. vesicles. pustules. cysts.
vesicles. Explanation: The lesions form herpes zoster are vesicles, defined as circumscribed, elevated, palpable masses that contain serous fluid and are less than 0.5 cm in diameter. Wheals are elevated masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated fluid-filled or semisolid masses in the subcutaneous tissue or dermis.
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of albinism. anemia. vitiligo. local arterial insufficiency.
anemia. Explanation: In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky white spots. Local arterial insufficiency is characterized by marked localized pallor.
The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as petechiae. ecchymosis. spider angioma. telangiectasia.
petechiae. Explanation: Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.
A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response? "To eliminate cerumen, flush the ears with water when you shower." "The amount of earwax lessens with aging." "Earwax is made by glands in your ears." "More earwax is made when an infection is present."
"Earwax is made by glands in your ears." Explanation: Earwax or cerumen is made by specialized apocrine glands called ceruminous glands, which are found in the external ear where they produce cerumen or wax. There is no evidence that the amount of earwax lessens with aging. Flushing the ears with water when showering will not reduce the amount of cerumen produced. There is no evidence that cerumen increases when an infection is present.
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? Concave Discolored Clubbing Brittle
Clubbing Explanation: Clubbing of the nails is evidenced by an angle greater than 160°, and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or "spooning" may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.
The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? Flat with skin color change Elevated and palpable Circumscribed border Greater than 1 cm in diameter
Elevated and palpable Explanation: The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, nonpalpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.
A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high? Conduction Radiation Convection Evaporation
Evaporation Explanation: Mechanisms for heat loss from the body include convection, conduction, radiation, and evaporation. Normally all of these mechanisms are used. However, when the ambient temperature is very high, radiation and convection are ineffective. Evaporation becomes the only means for heat loss.
During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? Long-standing cardiopulmonary disease Fungal infection Poor circulation Iron deficiency anemia
Iron deficiency anemia Explanation: The concave shape of the nails, referred to as spooning, is a sign of iron deficiency anemia. Clubbing of the nails, at greater than a 160-degree angle, suggests long-standing cardiopulmonary disease. Nails thicken when there is a fungal infection and poor circulation
Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? Patch Papule Plaque Macule
Macule Explanation: A flat, nonpalpable, circumscribed lesion less than 1 cm is a macule. A patch is a macule larger than 1 cm, and possibly with an irregular border. A papule is an elevated palpable solid mass with a circumscribed border and less than 0.5 cm. A plaque is a papule greater than 0.5 cm.
A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: Palpable, solid tumors >3 cm. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Flat macules with irregular borders. Flat, mole-like lesions.
Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Explanation: Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid
Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? Pustule Cyst Spider angioma Erosion
Spider angioma Explanation: A spider angioma is a vascular lesion. Erosion is a secondary lesion. Pustules and cysts are classified as primary skin lesions.
When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water? Stratum granulosum Stratum lucidum Stratum germinativum Stratum corneum
Stratum corneum Explanation: The stratum corneum, the outermost layer of the epidermis, has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture in the subcutaneous tissues. The other layers do not have this capacity.
Sudoriferous glands secrete which type of substance? Sweat Oil Cerumen Hormones
Sweat Explanation: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.
A nurse is preparing a presentation for a local senior citizen group about skin care and changes that occur with aging. The nurse plans to include measures to reduce the risk of minor trauma based on the understanding about which of the following? The thinning of epidermal-dermal junction promotes shearing. The loss of melanin makes the skin more vulnerable to injury. Sebum secretion decreases resulting in more fragile skin. Loss of subcutaneous tissue diminishes protection of underlying tissues.
The thinning of epidermal-dermal junction promotes shearing. Explanation: Cellular changes occur with aging which leads to thinning at the junction of the dermis and epidermis leading to fewer anchoring sites between the two skin layers. This means that even minor injury to the epidermis can cause it to shear away from the dermis, accounting for the increased vulnerability to trauma. The loss of melanin impacts pigmentation such as of the hair. Loss of subcutaneous tissue diminishes the protection and cushioning of the underlying tissues and organs. This may lead to increased injury but not injury related to minor trauma. Reduced sebum secretion leads to dry and scaly skin.
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? Yellow Bronze Gray Orange-green
Bronze Explanation: Patients diagnosed with Addison's disease have a bronzed appearance, an "external tan." Yellowish skin is noted in the patient diagnosed with jaundice. Patients with renal failure may have a gray or orange-green cast to the skin.
A nurse on assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement? Monitor normal variation in skin color. Provide addtional blankets for this client. Lower the thermostat in the client's room. Check the client's oral temperature.
Check the client's oral temperature. Explanation: Erythema is pink or a red skin shade that is caused by dilation of the capillaries. In clients who are more light-skinned, it is easily observable. Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. This color may be seen when there is inflammation or fever, so checking the client's oral temperature should be the nurse's priority. Once the client's temperature is established, interventions such as lowering the thermostat in the room, providing additional blankets, and/or conducting a more detailed assessment can be determined. A change in the client's skin color should always be investigated.
A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment? Dull or yellow-brown shade to his chest Ashen gray and dull color to his face Cherry red color to the nail beds, lips, and oral mucosa Purplish tinge to the hands
Cherry red color to the nail beds, lips, and oral mucosa Explanation: Dark pigment responds with discoloration after injury or inflammation, and patients with dark skin more often experience postinflammatory hyperpigmentation than do those with lighter skin. Cherry red nail beds, lips, and oral mucosa are skin color changes that occur early with carbon monoxide poisoning. Refer to Table 51-2 in the text.
Which term describes the transfer of heat from the body to a cooler object in contact with it? Conduction Evaporation Radiation Lichenification
Conduction Explanation: Conduction is one of the three major physical processes are involved in loss of heat from the body to the environment. Radiation is the transfer of heat to another object of lower temperature situated at a distance. Lichenification is the leather thickening of the skin. Convection consists of movement of warm air molecules away from the body.
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced? Conduction Radiation Evaporation Convection
Conduction Explanation: Three major physical processes are involved in loss of heat from the body to the environment. The first process—radiation—is the transfer of heat to another object of lower temperature situated at a distance. The second process—conduction—is the transfer of heat from the body to a cooler object in contact with it. The third process—convection, which consists of movement of warm air molecules away from the body—is the transfer of heat by conduction to the air surrounding the body.
Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? Vitiligo Hirsutism Lichenification Telangiectases
Vitiligo Explanation: Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.
A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum? contributing to acidity of perspiration to decrease microbial growth trapping debris in the external ear prevents drying and cracking of the skin and hair cooling overwarm skin
prevents drying and cracking of the skin and hair Explanation: Sebum, which is an oily lubricant, prevents drying and cracking of the skin and hair.
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? Vesicles Bullae Pustules Cysts
Vesicles Explanation: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions.
During an interview, a middle-aged male patient states, "My hair is starting to turn gray." The nurse demonstrates understanding of this change by responding with which statement? "There is probably an underlying genetic problem causing it." "You probably had too much exposure to the sun when you were younger." "As you get older, your hair begins to lose its pigment." "It's really nothing to worry about at this point in time."
"As you get older, your hair begins to lose its pigment." Explanation: Gray or white hair reflects the loss of pigment that occurs with aging. The color change is not related to sun exposure or a genetic problem. Telling the patient that it is nothing to worry about ignores the patient's statement, which suggests that he is concerned about the change.
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? "Have you been in the sun a lot?" "Have you been eating a large amount of carotene-rich foods?" "Have you been diagnosed with Addison's disease?" "Have you been ingesting large quantities of alcohol?"
"Have you been eating a large amount of carotene-rich foods?" Explanation: The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.
A nurse is instructing a client with paronychia about general functions of the nails. The nurse considers the teaching successful when the client makes which statement? Select all that apply. "Nails should be cut low to prevent scratching and injuring the skin" "Nails grow faster in the toenails than the fingernails and growth tends to slow with aging." "The nail grows from its root, which lies under a thin fold of skin called the cuticle." "Nails protect the sensory functions of the fingers and toes and assist in grasping small items" "If my fingernail falls off, it would take about six months to completely regenerate"
"If my fingernail falls off, it would take about six months to completely regenerate" Explanation: The nail grows from its roots, which lies under thin fold of skin called the cuticle. Nail functions include scratching. Trimming the nails can be of psychosocial importance and is related to grooming and appearance. A client should be instructed not to dig so deep as to injure the skin or cause bleeding. Lotions, ointments, and bathing products can assist if pruitis persists. Nails also protect the highly developed sensory functions of fingers and toes to assist in grasping small items. Nail growth is continuous throughout life, with an average growth of 0.1 mm daily. Growth is faster in fingernails than toes and tends to slow with aging. Complete regeneration of a fingernail takes about six months whereas toe regeneration takes about 18 months. In general, the nails should be assessed for confirmation, color, and consistency. Inflammation of the skin around the nail accompanied by tenderness and erythema indicates paronychia.
A nurse is providing care to a patient who is receiving chemotherapy. The nurse notes that the patient has lost most of the hair on her head. The nurse documents this finding as which of the following? Hypopigmentation Jaundice Photosensitivity Alopecia
Alopecia Explanation: A generalized loss of hair is termed alopecia. Jaundice refers to a yellow discoloration of the skin due to excess amounts of serum bilirubin. Photosensitivity refers to a condition in which the skin reacts to sun exposure. Hypopigmentation refers to a loss of skin pigment.
A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client? The client should consider changing careers as stress plays a significant role in this condition. Recommend the client speaks with a health care provider about currettage which is the most common treatment. Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Reassure the client that the condition usually resolves if dietary restrictions limiting caffeine and alcohol are followed.
Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Explanation: Actinic ketatosis, sometimes referred to as solar keratosis, is a plaque skin condition caused by long-term exposure to ultraviolet light. A plaque is a group of coalesced papules with a flat top. Of the choices presented, the best advice the nurse can give the client is to instruct them about preventive measures to avoid direct sun or ultraviolet light. This could prevent future breakouts since this condition can reoccur. This condition develops over a number of years and typically affects clients over 40, who work outdoors frequently, sunbath, or tan. This condition is not directly related to stress. Changing career fields is not be a practical or necessary intervention for this client. While the condition could resolve itself, the client should seek medical advice as some studies suggest a precancerous component. Dietary restrictions, limiting caffeine and alcohol do not have a direct correlation related to this condition. The most common surgical intervention is cryotherapy.
Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate? Thighs Axillae Eyebrows Beard
Beard Explanation: The rate of hair growth varies. Beard growth is the most rapid, followed by hair on the scalp, axillae, thighs, and then eyebrows.
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? Clubbing Beau's line Splinter hemorrhage Paronychia
Beau's line Explanation: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.
The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based? Eczema Xanthelasmas Seborrheic keratosis Rash
Eczema Explanation: There are some skin conditions that are genetically based. Eczema is one such condition that does not have a distinct inheritance pattern but does have a genetic predisposition for the condition. Rash is not considered a genetically based skin condition. Xanthelasmas or yellowish waxy deposits on the upper and lower eyelids and seborrheic keratoses or crusty brown patches are both considered benign skin changes in the skin of an older adult.
The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply. Evaluate the client's level of pain, using a numeric value pain scale. Palpate the client's skin for moisture, temperature, and texture. Ask the client whether the wound bed or surrounding skin itches. Review the client's prothrombin time test and international normalized ratio. Measure and assess the client's wound bed, size, edges, and margins.
Evaluate the client's level of pain, using a numeric value pain scale. Ask the client whether the wound bed or surrounding skin itches. Palpate the client's skin for moisture, temperature, and texture. Measure and assess the client's wound bed, size, edges, and margins. Explanation: If wounds are found on inspection of the skin, a comprehensive assessment should be made and documented. The assessment should include the wound size and measurement to determine the diameter and depth of the wound and surrounding erythema. The wound bed should be inspected for necrotic and granulation tissue, epithelium, exudate, color, and odor. The surrounding skin should be assessed for color, suppleness, itching and scaling. The edges and margins should be assessed for undermining. Skin moisture, temperature and texture are assessed primarily by palpation. The nurse should also assess for other signs and symptoms associated with new skin problems such as pain, burning, or pruritis. Pain or its absence can be associated with the staging of wounds and possible necrosis not visibly seen. Reviewing the prothrombin time test (PTT) and international normalized ratio (INR) may not directly correlate with priority interventions for this wound, but could explain new findings of skin ecchymosis should these values be medically elevated by medications.
Which of the following actions helps the nurse to determine the quality of the skin turgor? Grasping the skin Palpating the skin Inspecting the palmar surface Placing the dorsum of the hand on the surface of the skin
Grasping the skin Explanation: The nurse determines the quality of the skin turgor by grasping the skin such as that over the sternum, between the thumb and forefinger. Normally the skin returns to its original position immediately after being released. Placing the dorsum of the hand on the surface of the skin helps in assessing the temperature. The nurse can detect moisture with the palmar surface, but the nurse cannot determine the quality of the skin by palpating.
During assessment of the integumentary system, the nurse notes patches of white skin on an African American man. The nurse knows that the lack of production of melanin could be related to a deficiency of a hormone from the: Thyroid gland. Pancreas. Hypothalamus. Pituitary gland.
Hypothalamus. Explanation: Production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. Melanin provides a natural protection against the harmful effects of ultraviolet light; however, it does not provide complete protection from damaging rays of the sun.
An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding? It is an ecchymosis that is associated with trauma and bleeding. It is a telangiectasia that is associated with varicose veins. It is a spider angioma that is associated with liver disease. It is a cherry angioma that is a normal age-related skin alteration.
It is a cherry angioma that is a normal age-related skin alteration. Explanation: A cherry angioma is a papular and round area that is red, found on extremities, and may blanch with pressure. This lesion is considered a normal age-related skin change. A spider angioma is red with a central body and radiating branches that is associated with liver disease. A telangiectasia has a shape like a spider that is caused by the dilation of venous vessels and varicose veins. Ecchymoses are round or irregular macular lesions that vary in color and are associated with trauma or bleeding.
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? Jaundice Bronzed appearance Pallor Cherry red face
Jaundice Explanation: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin (>2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes.
The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as? Keloid Lichenification Scar Atrophy
Keloid Explanation: Keloid is hypertrophied scar tissue secondary to excessive collagen formation during healing, such as from ear piercing or surgical incision. It has an elevated, irregular, red appearance and occurs more often in African Americans.
Which factor causes wrinkles among older adults? Decrease in melanin Decrease in estrogen production Loss of subcutaneous tissue Decrease in sebum
Loss of subcutaneous tissue Explanation: The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.
Which of the following pigments influences hair color? Melanin Keratin Sebum Pheromones
Melanin Explanation: Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Sebum is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? Macule Vesicle Cyst Pustule
Pustule Explanation: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? Reduction in melanin production Reduction in the elasticity of the skin Reduction in sebum production Reduction in estrogen production
Reduction in sebum production Explanation: The sebum is a lubricant that prevents the drying and the cracking of the skin and hair. Due to aging, the skin becomes dry and flaked as sebum production is reduced. Loss of elasticity of the skin causes wrinkles among older adults. Reduction in melanin results in gray hair. Facial hair and sometimes chest hair appear in postmenopausal women as a result of the decreased production of estrogen.
The nurse is preparing a teaching tool on the functions of the skin. Which information about the skin will the nurse include on this tool? Select all that apply. Aids in maintaining fluid balance Helps regulate body temperature Serves as a sensory organ Protects the body from microorganisms Supplies oxygen to the underlying tissues
Serves as a sensory organ Aids in maintaining fluid balance Helps regulate body temperature Protects the body from microorganisms Explanation: The skin serves several functions. The skin provides a sensory function as the receptor endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. The skin aids in maintaining fluid balance because the stratum corneum absorbs water and prevents an excessive loss of water and electrolytes from the internal body as well as retains moisture in the subcutaneous tissues. The skin helps regulate body temperature through radiation, conduction, and convection. The skin provides a covering over the skin and serves as a highly effective protection against invasion by bacteria and other foreign matter. Oxygenated blood supplies oxygen to the underlying tissues.
Petechiae are associated with which of the following disorders? Deep vein thrombosis Acute respiratory distress syndrome (ARDS) Thrombocytopenia Pulmonary emboli
Thrombocytopenia Explanation: Petechiae are small lesions that are red or purple in color. They are associated with broken capillaries or indicative of platelet abnormalities, specifically thrombocytopenia. Petechiae are not associated with deep vein thrombosis, pulmonary emboli, or ARDS.
The nurse is preparing to assess a client's integumentary status. Which charactertistics of the skin will the nurse assess by using the technique of palpation? Select all that apply. Edema Turgor Signs of infestation Elasticity Color
Turgor Edema Elasticity Explanation: Inspection and palpation are the techniques used to examine the skin. Palpation is used to assess for skin turgor, edema, and elasticity. Inspection is used to assess for color and signs of infestation.
Which diagnostic test is used to examine cells from herpes zoster? Patch testing Tzanck smear Skin biopsy Skin scrapings
Tzanck smear Explanation: A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scraping is used to diagnose spores and hyphae. A patch test is used to identify substances to which the client has developed an allergy.