Prep u chapter 55 Assessment of integumentary system

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?

"As you get older, your hair begins to lose its pigment. 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 eating a large amount of carotene-rich foods?" 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.

Which cells play a role in cutaneous immune system reactions?

Langerhans' cells Langerhans' cells are accessory cells of the afferent immune system that play a role in cutaneous (skin) immune system reactions. These cells process invading antigens and transport the antigens to the lymph system to activate the T lymphocytes. Merkel cell are receptors that transmit stimuli to the axon through a chemical synapse and therefore are associated with the sense of touch. Melanocytes are the cells that give skin its pigment.

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification Lichenification is a thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue 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.

During a routine appointment, a young client presents a piece of hand drawn artwork to the doctor. The client has a "lump of skin" on the longest digit the right hand—the client's coloring hand. What is the pathophysiology behind this lump? Select all that apply.

accelerated epidermal cell production callus Areas of the skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin.

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

anemia. 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 purpose of melanin is to:

determine skin color 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 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?

prevents drying and cracking of the skin and hair Sebum, which is an oily lubricant, prevents drying and cracking of the skin and hair.

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? a. Vitiligo b. Psoriasis c. Melanoma d. Petechia

B. Psoriasis Rationale: 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.

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 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?

Beau's line 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.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

Bronze 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 client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars? a) Senile lentigines b) Senile keratosis c) Rheumatoid nodules d) Calluses

Calluses Areas of skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin. Senile keratosis is small, yellow or brown raised lesions that appear on the face and trunk in an older adult client. Senile lentigines are also known as liver spots and are found on the hands and forearms of older people. Rheumatoid nodules affect those clients with rheumatoid arthritis.

The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?

Carbon monoxide poisoning Cherry red nail beds, lips, and oral mucosa in a dark-skinned person are signs of carbon monoxide poisoning.

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?

Check the client's oral temperature. 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.

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 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 type of heat loss is caused by a cool breeze that blows across the body surface?

Convection Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body. Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water.

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? a) Brittle b) Concave c) Discolored d) Clubbing

D. Clubbing Rationale: 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 reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based?

Eczema 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 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?

Elevated and palpable 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 teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.

Fingernails Hair Skin 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.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

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

Freckles Lentigines are freckles. Xerosis is dryness. Neurodermatitis is itchy spots. Xanthelasma is the yellowish waxy deposits on the upper and lower eyelids

Which of the following actions helps the nurse to determine the quality of the skin turgor?

Grasping the skin 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.

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review

Hemoglobin and hematocrit Normal nails appear slightly convex with a 160° angle between the nail base and the skin. Concave-shaped nails, referred to as "spooning" because of their characteristic appearance, are a sign of iron-deficiency anemia. ABGs, BUN and creatinine, and glucose levels are not related to this shape of nail.

Production of melanin is controlled by a hormone secreted by which gland?

Hypothalamus Explanation: The production of melanin is influenced by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone, among other factors. Production of melanin is not controlled by the thyroid, adrenal, or parathyroid gland.

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 a cherry angioma that is a normal age-related skin alteration. 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.

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid The hypertrophied, elevated, irregular scar would be documented as a keloid. Lichenification refers to thickening and roughening of the skin or accentuated skin markings that may be due to repeated rubbing, irritation, or scratching. A nodule refers to an elevated, palpable solid mass that extends into the dermis. Cicatrix is another term used to denote a scar.

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area

Oral mucosa In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjunctivae, oral mucosa, and nail beds.

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test Rationale: Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens, such as nickel or fragrances, to normal skin under occlusive patches. Patients wear these occluded strips on their backs for 48 hours, and the area is assessed after 72 hours

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?

Pearly white substance that is attached to the hair shaft that is not removed with brushing Rationale: 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?

Petechiae Rationale: 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 is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted?

Purple-gray cast 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. Reference:

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as:

Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Rationale: Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.

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 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.

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 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.

Biopsies are performed on which of the following? Select all that apply.

Skin nodules Plaques Ulcers Blisters

Sudoriferous glands secrete which type of substance?

Sweat Rationale: 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 client is concerned about finding a few strands of hair on a pillow after sleeping and additional strands on the brush when styling the hair. Which response will the nurse make regarding the client's concern?

There are approximately 100 strands of hair lost per day." Throughout a person's life, hair follicles undergo continuous cycles of growth, transition, and rest. The rate of growth varies and the hair follicle can be in a growth, involution, or resting phase. Approximately 5% to 10% of hair is in the resting phase when shedding occurs. A person will typically shed approximately 100 scalp hairs each day. Losing hair does not mean the hair follicle is dying. Finding hair strands on a pillow or brush is not unusual and does not need to be evaluated. Most people who lose hair do not have an undiagnosed illness.

Petechiae are associated with which of the following disorders?

Thrombocytopenia 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 examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? a. Macule b. Papule c. Vesicle d. Wheal

Vesicle A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).