Health Assessment PrepU Chp. 11

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? a. Basal cell carcinoma b. Iron deficiency anemia c. Cushing's disease d. Lupus erythematosus

c Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

When documenting that a client has freckles, the appropriate term to use is a. patches b. vesicles c. bullae d. macules

d Macules are skin discolorations that are flat, circumscribed, discolored, and less than 1 cm in diameter. An example of a macule is a freckle.

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

a (D) The skin is the largest organ of the body. It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of a. papules. b. plaques. c. macules. d. bulla.

c Freckles are flat, small macules of pigment that appear following sun exposure.

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? a. It is likely to be related to her lupus. b. It should not cause any problems. c. It is likely to be related to an exposure to a chemical. d. It is likely to be related to an allergic reaction.

a A "palpable purpura" is usually associated with a vasculitis. This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and mimic many other diseases. While allergic and chemical exposures may be a possible cause of the rash, this client's SLE should make the nurse consider vasculitis.

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? a. body temperature b. pulse oximetry c. bowel sounds d. heart sounds

b A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of a. fissures. b. scales. c. erosion. d. ulcers.

a Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate? a. The elderly should only bathe or shower once a week b. The elderly should bathe or shower only every 2 to 3 days c. The elderly should bathe or shower once every 2 weeks d. The elderly should bathe or shower daily but use lots of moisturizer

b Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? a. "It means you have skin cancer and need to have them removed." b. "These areas need to be cleansed daily and covered with a dry gauze bandage." c. "These are considered a normal age-related change in the skin." d. "I will report these to the health care provider so that medication can be prescribed."

c Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.

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

c The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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? a. Macule b. Vesicle c. Papule d. Nodule

a A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? a. Seborrheic keratosis b. Pressure ulcer c. Cherry angioma d. Cutaneous horn

b An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.

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? a. Broken with the presence of a blister b. Unbroken but red in color c. Exposure of subcutaneous tissue and muscle d. Ulceration resembling a crater

a A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? a. The client has chronic hypoxia b. The client has melanoma c. The client has COPD d. The client has asthma

a Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

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 a. hypothyroidism. b. hypoparathyroidism. c. infectious conditions. d. hyperthyroidism.

a Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

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? a. The client may have been abused. b. The client may have peripheral vascular disease. c. The client is elderly. d. The client may have a cognitive deficit.

a Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

When the nurse is inspecting a client's fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer? a. Dermal b. Sebaceous c. Epidermal d. Subcutaneous

a The dermis is connected to the epidermis by means of papillae that form the base for visible swirls or friction ridges, which provide the unique pattern of fingerprints.

The nurse is preparing to examine a client's skin. What would the nurse do next? a. Expose only the body part that is being examined. b. Wear gloves when preparing to inspect the skin and nails. c. Ensure that the room is hot to prevent chilling. d. Have the client remove clothing from the upper body.

a When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? a. Squamous cells b. Sweat glands c. Subcutaneous tissue d. Sebum production

d Sebum production decreases with age, increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question? a. "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." b. "SPF 15 is the number of minutes that a person can safely stay in the sun after treating the skin with the product." c. "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn." d. "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

d The sun protective factor or SPF is a ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B sunrays. None of the other options present correct information regarding the meaning of SPF 15.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? a. Inspect the area b. Ask further questions c. Move on to next body system d. Document the statement

a If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? a. Local irritation can cause damage to the nail bed b. Abnormalities may be a sign of poor hygiene c. May affect a person's body image negatively d. Can be caused by an underlying systemic illness

d Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problem because they can be damaging to a person's self image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings? a. Pityriasis rosea b. Tinea infection c. Eczema d. Psoriasis

d This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? a. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." b. "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." c. Repeated sunburns in childhood may explain the presence of some of your moles. d. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young."

a Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding? a. Macule b. Papule c. Nodule d. Pustule

b A papule is a solid, elevated, circumscribed skin lesion that does not contain serous or purulent fluid. A macule is a flat nonpalpable skin color change usually less than 1 cm in size. A nodule is an elevated solid palpable mass between 0.5 to 2 cm in size. A pustule is pus-filled vesicle or bulla (circumscribed elevated mass).

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? a. Sunlight b. Wood's light c. Artificial light d. Flashlight

b The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

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? a. Skin warm and dry to the touch b. Denies any skin color changes c. Small lesion left forearm for one month d. Dry and flaky skin in the winter months

a Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

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 "ABCD" characteristic of malignant melanoma? a. Borders well demarcated b. Asymmetrical shape c. Color is uniform d. Diameter less than 6mm

b Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to1/4 inch (3-4mm), and E for elevated.

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

b Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

When preparing to examine a client's skin, which of the following would be most important for the nurse to do? a. Wear gloves when preparing to inspect the skin and nails b. Expose only the body part that is being examined c. Have the client remove clothing from the upper body d. Ensure that the room is warm to prevent chilling

b When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

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

c To assess turgor, gently pinch the skin over the clavicle with two fingers.

The nurse expects what change in a client's hair as a result of aging? a. The existing terminal hair will become coarser and less pigmented. b. The is an increase in the loss of fine, relatively unpigmented hair referred to as villus hair. c. Eyebrows will thin and gradually disappear. d. Sebaceous glands will secrete less causing hair to be drier.

d A decrease of sebum secreted by sebaceous glands occurs with age and results in drier hair. The remaining options are not true statements.