NSG303 Chapter 14: Assessing Skin, Hair, and Nails

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? Assists in keeping the skin intact Assists in friction protection Assists in protection from infection Assists in keeping skin dry

Correct response: Assists in friction protection Explanation: Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears greenish. ashen. bluish. olive.

Correct response: ashen. Explanation: Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

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 ulcers. erosion. scales. fissures.

Correct response: fissures. Explanation: 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

Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.

Correct response: vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

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

Correct response: dermis. Explanation: 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.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: symptoms of stress. recent radiation therapy. pigmentation irregularities. allergies to certain foods.

Correct response: symptoms of stress. Explanation: Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism? Moist and smooth Moist and rough Dry and smooth Dry and rough

Dry and rough Correct response: Dry and rough Explanation: A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 45-year-old female with 10 year history of cigarette smoking 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years

55-year-old male who lived in California for 20 years Explanation: 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.

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Deoxyhemoglobin Carotene Melanin

Correct response: Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as stage I. stage II. stage III. stage IV.

Correct response: stage II. Explanation: A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin? dermis adipose epidermis subcutaneous

Explanation: The dermis is well supplied with blood. It contains connective tissue, sebaceous glands, sweat glands, and hair follicles. It is the apocrine sweat gland that is responsible for adult body odor. These glands are not present in any other skin layer.

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin? Stratum corneum Stratum lucidum Dermis Epidermis

orrect response: Dermis Explanation: 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. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? Newton scale Head-to-toe assessment Norton scale Braden scale

Correct response: Braden scale Explanation: Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.

Local redness of the skin warns of impending necrosis. True False

Correct response: True Reference:

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? 1 2 3 4

3 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

The student nurse learns that examining the skin can do all of the following except? Reveal overhydration Allow early identification of neurologic deficits Identify physical abuse Allow early identification of potentially cancerous lesions

Correct response: Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

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? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus

Correct response: Cushing's disease Explanation: 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.

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

Correct response: D. Explanation: 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.

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn? The damage to keratin producing cells in the epidermis layer Destruction of hair follicles located in the dermis layer The impairment of apocrine gland to function effectively in the subcutaneous layer The ability of the adipose layer to produce carotene has been destroyed

Correct response: Destruction of hair follicles located in the dermis layer Explanation: Damage to hair follicles located in the dermis layer of the skin would result in the body's inability to regrow hair on burn damaged areas. The remaining options suggest correct information but none are associated with the regrowth of hair after a burn.

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply. Disturbed Body Image Ineffective Individual Coping Anxiety Impaired Skin Integrity Risk for Infection

Correct response: Disturbed Body Image Ineffective Individual Coping Anxiety Explanation: This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection.

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding? Assess the client for changes in sensation due to vascular problems Monitor the client for additional findings of cystic fibrosis Suggest that the client use antiperspirant products Document the findings in the client's record as normal

Correct response: Document the findings in the client's record as normal Explanation: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating.

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse? Ask the client about any injury to the nails Document this as a normal finding Report the finding to the health care provider Assess for adequate capillary refill time

Correct response: Document this as a normal finding Explanation: The nurse should consider the freckle-like pigmentation in the nail beds of the client as a normal finding in dark-skinned people. The variations are due to different amounts of melanin in certain areas. Asking the client about injury to the nail and reporting the finding to the health care provider are not appropriate because there is no pathology involved. Pressing the pigmented area to assess for blood flow is not necessary because there is no evidence of inadequate circulation to the nail beds.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? Allow the client to pray before the examination Let the client remained fully dressed for the examination Have a nurse who is the same sex as the client examine him Avoid asking any questions regarding the client's lifestyle

Correct response: Have a nurse who is the same sex as the client examine him Explanation: Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

The RN should intervene and further educate the nursing assistant when observing which action? Independently pulling an immobile client up in bed Assisting feeding a client ground chicken with dentures in place Ambulating a client using a walker in the hallway Propping a client on the side using pillows under the hip, knees, and shoulder

Correct response: Independently pulling an immobile client up in bed Explanation: Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.

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

Correct response: Inspect the area Explanation: 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.

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis

Correct response: Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterio

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 Involved in digestion of food Protects against damage to the body from sunlight Circulates blood throughout the body Helps make vitamin D in the body Aids in maintaining body temperature

Correct response: 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 Explanation: 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.

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) Depth Location Other lesions on body Size Texture

Correct response: Location Size Texture Explanation: A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or the depth of the lesion.

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Limbs Vertex Eyebrows Palmar surfaces

Correct response: Palmar surfaces Explanation: The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.

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? Eczema Pityriasis rosea Psoriasis Tinea infection

Correct response: Psoriasis Explanation: 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 assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy

Correct response: Psoriasis, fungal infections, trauma Explanation: Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client? Cystic acne Pustular acne Bullous impetigo Chickenpox

Correct response: Pustular acne Explanation: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do? Reassure the mother that this is normal. Obtain an echocardiogram to check for structural heart disease and consult cardiology. Admit the child to the hospital for further observation. Question the validity of the mother's story.

Correct response: Reassure the mother that this is normal. Explanation: This is an example of peripheral cyanosis, a very common and benign condition that typically occurs when the child is slightly cold and adjusting peripheral circulation to keep the core warm. Without other problems there is no need for further workup. If the lips or other central locations are involved, the nurse must consider other etiologies.

When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.) Red or light hair Freckles Immunosuppression Female gender Age older than 60

Correct response: Red or light hair Freckles Immunosuppression Explanation: Risk factors for melanoma: history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sun exposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data? Risk for Imbalanced Body Temperature Altered Tissue Perfusion Risk for Impaired Skin Integrity Disturbed Body Image

Correct response: Risk for Impaired Skin Integrity Explanation: The nursing diagnosis of Risk for Impaired Skin Integrity can be confirmed because of the presence of thickened toenails that may cause damage to the epidermis of the skin on the lower extremities. There is no data to support the presence for Risks of Imbalanced Body Temperature or Altered Tissue Perfusion. The client has not mentioned any criteria to support a Disturbed Body Image.

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

Correct response: Skin warm and dry to the touch Explanation: 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.

Which of the following is an important function of the skin? Synthesis of vitamin D Production of carotene Maintenance of acid-base balance Protection against melanin deposits

Correct response: Synthesis of vitamin D Explanation: A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.

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? The client has chronic hypoxia The client has melanoma The client has COPD The client has asthma

Correct response: The client has chronic hypoxia Explanation: 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.

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

Correct response: The client may have been abused. Explanation: Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

Why is it important for the nurse to ask the client what they think caused a skin condition? The client's perception affects the approach and effectiveness in treating the skin condition The nurse can alleviate the client's fears about what caused the skin condition Doing so allows the client to decide what treatment is the best course of action Doing so encourages the client to use home remedies to reduce medical co

Correct response: The client's perception affects the approach and effectiveness in treating the skin condition Explanation: The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies.

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?

Correct response: Tinea corporis Explanation: 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.

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

Correct response: UV radiation exposure Explanation: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese? Anterior chest Upper abdomen On the neck Under the breast

Correct response: Under the breast Explanation: The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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

Correct response: Wood's light Explanation: 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.

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs? a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter greater than 6 mm; e = evolution

Correct response: a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution Explanation: This is the correct description for the mnemonic.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. entire skin surface. soles of the feet. adipose tissue.

Correct response: areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

Correct response: caused by aging of the skin in older adults. Explanation: Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown? high mild moderate negligible

Correct response: high Explanation: This client is at a high risk for skin breakdown because of activity (bedfast), poor nutritional status (never eats a complete meal), and immobility (occasionally moves in bed). A person who is independent with mobility and has a good nutritional status would have a mild or negligible risk for skin breakdown. A client who spends sometime in the same position and consumes half of required nutrients would have a moderate risk for skin breakdown.

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 hypothyroidism. hyperthyroidism. infectious conditions. hypoparathyroidism.

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

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1intact, firm skin with redness 2ulceration involving the dermis 3full-thickness skin loss 4necrosis with damage to underlying muscle

Correct response: intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially basal cell carcinoma. actinic keratoses. squamous cell carcinoma. malignant melanoma.

Correct response: malignant melanoma. Explanation: Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma.

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? heart sounds bowel sounds pulse oximetry body temperature

Correct response: pulse oximetry Explanation: 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.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is ineffective individual coping related to changes in appearance. anxiety related to loss of outdoor activities and altered skin appearance. dry flaking skin and dull dry hair as a result of disease. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

Correct response: risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. Explanation: Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as stage I. stage II. stage III. stage IV.

Correct response: stage II. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Connecting the skin to underlying structures is/are the papillae. sebaceous glands. dermis layer. subcutaneous tissue.

Correct response: subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

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? alopecia hirsutism tinea capitis trichotillomania

Correct response: trichotillomania Explanation: 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.

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 nodules. bullae. vesicles. wheals.

Correct response: vesicles. Explanation: 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.

A client's skin color depends on melanin and carotene contained in the skin, and the client's genetic background. volume of blood circulating in the dermis. number of lymph vessels near the dermis. vascularity of the apocrine glands.

Correct response: volume of blood circulating in the dermis. Explanation: The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.