Health assessment Skins nails hair

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?

Tinea corporis *In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis. *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.

Squamous cell carcinoma is associated with

overall amount of sun exposure. *Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?

trichotillomania *Trichotillomania or compulsive hair pulling is associated with a psychiatric disorder. Alopecia is a term used to describe general hair loss, most often associated with male pattern baldness, or a loss of hair from medications such as chemotherapy. Hirsutism is the appearance of hair on the face of a female. Tinea capitis causes round areas of alopecia on the scalp of a person with a fungus infection.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers. *The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking *An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.

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 Surgical site warm to touch *Signs of surgical site infection include: pain or tenderness, localized swelling, redness, or heat. Hives are not indicative of surgical site infection; localized swelling is more likely to occur with infection.

While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric *Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape. Vascular lesions range in size from 1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs. Primary skin lesions can be flat, raised, or fluid filled. They can be of various colors, shapes, and textures. Secondary skin lesions can have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning *Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness. *Beau's lines occur after acute illness and eventually grow out.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue *Blue-green fluorescence indicates fungal infection.

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

Squamous cell carcinoma is associated with

overall amount of sun exposure *Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

15 *BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years *The greatest risk factors are sun exposure, and those individual with light skin, freckles, and red hair. Skin cancer risk also increases with male gender and advancing age. The older male, who lived in California, because of the sun exposure, is at greatest risk for skin cancer.

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client. *Friction and shear forces are risk factors for developing pressure ulcers. The nurse should ask for help and use a draw sheet to avoid shearing forces. Pulling the client up in bed and allowing the client to slide in bed create friction and shear forces. Pushing the client also creates shearing forces.

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red colour remains. What should the nurse do?

Consider admitting the client to the hospital. *Although this rash may not be impressive, the fact that they do not blanch with pressure is concerning. This generally means that there is pinpoint bleeding under the skin; while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. The nurse should always report this feature of a rash immediately.

When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient?

He has peripheral artery disease *Loss of hair on the legs may indicate peripheral artery disease, while changes in pubic or axilla hair may indicate hormonal problems.

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo *

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo *In vitiligo, depigmented macules appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment is normal skin color; the pale areas are vitiligo. The condition may be hereditary. These changes may be distressing to the patient.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a:

plaque Plaques are elevated, palpable, solid masses greater than 0.5 cm and may be coalesced papules with a flat top. Papules are also elevated, palpable, sold masses, but are smaller than 0.5 cm. Macules and patches are small, flat, nonpalpable skin color changes.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies *A serpiginous rash is snaking. This type of rash can be caused by scabies.

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease *Central cyanosis is a bluish-tint to the lips, tongue, and oral mucosa. Causes of central cyanosis include advanced lung disease. Pallor is associated with anemia. Jaundice is associated with liver disease. Cyanosis in congestive heart failure is usually peripheral, reflecting decreased blood flow.

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm. *To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the patient's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis *Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

Existence of systemic diseases that have skin manifestations *One purpose of the integumentary health history is to identify systemic diseases that have skin manifestations. Questions to determine systemic diseases that the patient may have include asking about prescribed medications, immunizations, and diagnosed illnesses. Such a history would provide little information regarding health promotion care, or risks for skin cancer or skin ulcer formation.

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo *Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthum is a macular or papular rash that is present along with a viral infection.

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal *A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. An erosion is a loss of superficial epidermis that does not extend to the dermis.

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.

- Largest organ of the body - Protects against damage to the body from sunlight - Helps make vitamin D in the body - Aids in maintaining body temperature *The skin is the largest organ of the body. The skin 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. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.

The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?

Skin that feels boggy on palpation *Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial