Chapter 60: Assessment of Integumentary Function

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?

Dermis

The purpose of melanin is to:

Determine skin color

Production of melanin is controlled by a hormone secreted by which of the following?

Hypothalamus

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas?

Sclerae

Which of the following pigments influences hair color?

Melanin

The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?

Conduction

A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response?

"Earwax is made by glands in your ears."

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 eating a large amount of carotene-rich foods?"

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.

- Serves as a sensory organ - Aids in maintaining fluid balance - Helps regulate body temperature - Protects the body from microorganisms

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.

- Turgor - Edema - Elasticity

The nurse is caring for an adult patient with a normal body temperature. What should the nurse know would be the approximate insensible water loss per day in this patient?

600 mL/day

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of:

Anemia

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?

Beard

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?

Freckles

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?

Purplish cutaneous lesions

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?

Pustule

When conducting a skin assessment, the nurse notes a purple macular lesion on the client's right upper extremity. The nurse differentiates the lesion as a petechia or ecchymosis based on:

Size

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?

Spider angioma