PrepU Ch.11; Nursing Assessment

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) 1. asymmetry 2. pink color 3. notched border 4. diameter great than 6 mm

1. asymmetry 3. notched border 4. diameter great than 6 mm

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1. ulceration involving the dermis 2. necrosis with damage to underlying muscle 3. intact, firm skin with redness 4. full-thickness skin loss

1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. 1. Admitting diagnosis 2. Activity 3. Moisture 4. Age 5. Nutrition

2. Activity 3. Moisture 5. Nutrition

The nurse notes that a 30-year-old female has hair on the chin and upper lip. What should the nurse consider as causing this growth of facial hair? Select all that apply. 1. Undiagnosed diabetes 2. Cushing disease 3. Side effect of steroid use 4. Polycystic ovary syndrome 5. Vitamin B-complex deficiency

2. Cushing disease 3. Side effect of steroid use 4. Polycystic ovary syndrome

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. 1. changing position frequently 2. shearing that occurs when sliding down in bed 3. moisture being allowed to accumulate on the skin 4. pressure that impairs capillary blood flow to the skin 5. friction created by dragging the skin against bedlinen

2. shearing that occurs when sliding down in bed 3. moisture being allowed to accumulate on the skin 4. pressure that impairs capillary blood flow to the skin 5. friction created by dragging the skin against bedlinen

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? a. "Are you allergic to foods, medications, or other substances?" b. "Does anyone else in your family have a rash like this?" c. "What have you been doing to control the itching?" d. "How painful is your rash?"

a. "Are you allergic to foods, medications, or other substances?"

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse? a. "How has it changed?" b. "Do you know how to check for signs of skin cancer?" c. "When did you notice the change?" d. "Sometimes moles change as you age."

a. "How has it changed?"

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

a. "These are considered a normal age-related change in the skin."

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? a. Acne b. Varicella c. Psoriasis d. Herpes simplex

a. Acne

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? a. Hypoxia b. A normal finding c. Vitamin C deficiency d. Infection

a. Hypoxia

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? a. Impetigo b. Herpes zoster c. Viral Exanthem d. Psoriasis

a. Impetigo

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what? a. Peripheral cyanosis b. Reynaud disease c. Central cyanosis d. Neurofibromatosis

a. Peripheral cyanosis

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? a. Petechiae b. Cherry angioma c. Ecchymosis d. Purpura

a. Petechiae

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer? a. Skin tags are common benign skin lesions b. Skin tags need to be removed as soon as possible or they will keep growing c. Skin tags can turn into skin cancer if they are not removed d. Skin tags are an early precursor to more serious skin cancer conditions

a. Skin tags are common benign skin lesions

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. Dry and flaky skin in the winter months c. Small lesion left forearm for one month d. Denies any skin color changes

a. Skin warm and dry to the touch

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? a. Spooning b. Clubbing c. Paronychia d. Beau's lines

a. Spooning

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? a. Stage II b. Stage IV c. Stage I d. Stage III

a. Stage II

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 asthma c. The client has melanoma d. The client has COPD

a. The client has chronic hypoxia

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? a. The cyanosis may be a result of a prolonged period of exposure to the cold. b. The client's arterial blood will appear bluish when observed in the test tube. c. The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood. d. The client is demonstrating central cyanosis.

a. The cyanosis may be a result of a prolonged period of exposure to the cold.

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 bathe or shower only every 2 to 3 days b. The elderly should only bathe or shower once a week c. The elderly should bathe or shower once every 2 weeks d. The elderly should bathe or shower daily but use lots of moisturizer

a. The elderly should bathe or shower only every 2 to 3 days

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? a. Tinea corporis b. Herpes simplex c. Tinea versicolor d. Multiple nevi

a. Tinea corporis

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

a. UV radiation exposure

The nurse in a clinic is caring for a 19-year-old male client who has a new onset of vesicles around the mouth and chin. The nurse completes an assessment, reviews data collected, and is determining which condition the client is experiencing. Complete the table of possible conditions by choosing from the list of assessment findings. a. Herpes simplex b. Cyst c. Impetigo

a. clustered, fluid-filled vesicles b. lesion that is walled off containing fluid or semisolid material c. bullae that rupture and ooze serous fluid forming a honey-colored crust

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

a. dermis.

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

a. fainting

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. erosion. c. ulcers. d. scales.

a. fissures.

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders? a. folliculitis b. alopecia c. ringworm d. tinea capitis

a. folliculitis

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? a. high b. negligible c. moderate d. mild

a. high

The nails, located on the distal phalanges of the fingers and toes, are composed of a. keratinized epidermal cells. b. stratum cells. c. ectodermal cells. d. endodermal cells.

a. keratinized epidermal cells.

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 a. vesicles. b. bullae. c. wheals. d. nodules.

a. vesicles.

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 a. vesicles. b. nodules. c. wheals. d. bullae.

a. vesicles.

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse? a. "Does nail biting run in your family?" b. "Do you feel anxious at times?" c. "Have you always bitten your nails?" d. "Have you been depressed lately?"

b. "Do you feel anxious at times?"

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? a. "Has anyone in your family ever been diagnosed with skin cancer?" b. "Do you take steroid medications on a regular basis?" c. "Have you ever been assessed for diabetes?" d. "What dietary supplements do you usually take?"

b. "Do you take steroid medications on a regular basis?"

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 "ABCDE" characteristic of malignant melanoma? .a Diameter less than 1/8 of an inch b. Asymmetrical shape c. Color is uniform d. Borders well demarcated

b. Asymmetrical shape

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. Can be caused by an underlying systemic illness c. Abnormalities may be a sign of poor hygiene d. May affect a person's body image negatively

b. Can be caused by an underlying systemic illness

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. Lupus erythematosus b. Cushing's disease c. Iron deficiency anemia d. Basal cell carcinoma

b. Cushing's disease

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

b. D.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? a. Color b. Distribution c. Arrangement d. Type

b. Distribution

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning? a. Minimizing the client's potential risk for pressure ulcer formation b. Existence of systemic diseases that have skin manifestations c. History of previous medical health promotion care d. Identifying the client's risk for developing skin cancer

b. Existence of systemic diseases that have skin manifestations

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? a. Crohns disease b. Hypothyroidism c. Cushing disease d. Diabetes mellitus

b. Hypothyroidism

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? a. Peripheral vascular disease b. Iron deficiency anemia c. Diabetes mellitus d. Vitamin A deficiency

b. Iron deficiency anemia

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 should not cause any problems. b. It is likely to be related to her lupus. c. It is likely to be related to an allergic reaction. d. It is likely to be related to an exposure to a chemical.

b. It is likely to be related to her lupus.

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? a. Refer the client for medical follow-up. b. Perform a random blood sugar test. c. Ask the client about a family history of cancer. d. Document the benign findings.

b. Perform a random blood sugar test.

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. Pressure ulcer

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? a. Transverse white lines in the nails b. Small pits in the surfaces of the nails c. Beau's lines d. White spots, or leukonychia, on the nail surfaces

b. Small pits in the surfaces of the nails

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

b. The client may have been abused.

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease? a. asking the client to stick out the tongue and assess the presenting surface. b. assessing the client's hard palate with a bright light. c. assessing the skin covering the client's elbow while applying moderate pressure d. asking the client to blink rapidly before assessing the palpebral conjunctiva of the eye

b. assessing the client's hard palate with a bright light.

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

b. macules.

The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a a. pustule b. papule c. wheal d. bulla

b. papule

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 a. patch. b. papule. c. plaque. d. macule.

b. papule.

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

b. pulse oximetry

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 minutes that a person can safely stay in the sun after treating the skin with the product." b. "SPF 15 is the number of times it takes to be applied to untreated skin before it will be able to effectively prevent sunburn." c. "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." d. "SPF 15 is the number of days that the product needs to be applied to untreated skin before it can effectively prevent sunburn."

c. "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? a. Trichotillomania b. Traction alopecia c. Alopecia areata d. Tinea capitis

c. Alopecia areata

Recommended protective measures to avoid skin cancer include which of the following? a. Performing monthly skin self-examinations b. Knowing signs of skin cancer c. Avoiding sun exposure d. Seeking biannual examination by a clinician after age 40 years

c. Avoiding sun exposure

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? a. Annular b. Linear c. Clustered d. Discrete

c. Clustered

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? a. Allow the client to pray before the examination b. Avoid asking any questions regarding the client's lifestyle c. Have a nurse who is the same sex as the client examine him d. Let the client remained fully dressed for the examination

c. Have a nurse who is the same sex as the client examine him

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? a. Treatment for fungal infections in the past b. Environmental exposure to chemicals c. History of cigarette smoking d. Onset of iron deficiency anemia

c. History of cigarette smoking

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic? a. Increased thickness and hair loss b. Pallor c. Increased thinness d. Erythema

c. Increased thinness

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

c. Inspect the area

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

c. Keloid formation at the site of an old incision

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? a. Disturbed Body Image b. Altered Tissue Perfusion c. Risk for Impaired Skin Integrity d. Risk for Imbalanced Body Temperature

c. Risk for Impaired Skin Integrity

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse? a. The client has had lice for quite some time b. The nits indicate the infestation is over c. The client had a recent infestation d. This is not lice; it is scabies

c. The client had a recent infestation

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? a. The client adheres to a vegetarian diet. b. The client has a surgical diagnosis. c. The client is consistently incontinent of urine. d. The client has a full-time caregiver.

c. The client is consistently incontinent of urine.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? a. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. b. There is noticeable bruising on and around the client's coccyx region. c. There is a non-blanching reddened area on the client's coccyx region. d. There is a generalized rash on the client's lower back and buttocks.

c. There is a non-blanching reddened area on the client's coccyx region.

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? a. Papule b. Crust c. Vesicle d. Bulla

c. Vesicle

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

c. Wood's light

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had a. radiation. b. steroid therapy. c. a recent illness. d. chemotherapy.

c. a recent illness.

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 a. precancerous lesions. b. signs of an infectious process. c. caused by aging of the skin in older adults. d. signs of dermatitis.

c. caused by aging of the skin in older adults.

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions? a. iron deficiency anemia b. fungal infection c. hypoxia d. psoriasis

c. hypoxia

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

c. subcutaneous tissue.

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

c. use two fingers to pinch the skin under the clavicle.

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

c. vellus.

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

d. Allow early identification of neurologic deficits

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? a. Decreased subcutaneous tissue b. Inadequate circulation c. Continuous trauma d. Excessive collagen formation

d. Excessive collagen formation

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

d. Expose only the body part that is being examined.

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. Nodule b. Papule c. Vesicle d. Macule

d. Macule

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? a. Palms b. Nail beds c. Sclera d. Oral mucosa

d. Oral mucosa

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

d. Psoriasis, fungal infections, trauma

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? a. Chickenpox b. Cystic acne c. Bullous impetigo d. Pustular acne

d. Pustular acne

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? a. The client's history of integumentary disorders b. The pigmentation of the client's skin c. The client's current medication regimen d. The client's ability to change position

d. The client's ability to change position

The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C? a. category b. characteristics c. consistency d. color

d. color

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 a. lice b. ticks c. allergies d. scabies

d. scabies

What role does oxyhemoglobin play in the physiological process that results in pallor? a. the loss of this component from the circulatory system b. the circulation of oxygen in the blood c. the increase of blue pigment in the venous system d. the reduction of red pigment in the arteries

d. the reduction of red pigment in the arteries