PrepU Chapter 14

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 II. 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.

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?

Peripheral cyanosis Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

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?

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

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 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.

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.

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

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

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

Burning when having an MRI A risk involved with tattooing includes burning sensations when undergoing magnetic resonance imagining (MRI). Tattoos does not affect x-rays, blood glucose levels, or response to dye injected for a CT scan.

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?

Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. 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.

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?

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. 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.

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

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.

Herpes simplex Clustered, fluid-filled vesicles Cyst Warm, moist, soft, and velvety areas Impetigo Elevated, palpable, solid mass

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

Hirsutism Excessive androgenic hormones in a female client can increase testosterone levels and cause masculinization changes, including hair in male distribution patterns. This hair growth is called hirsutism. Muscle cramps and cold sensitivity are associated with decreased thyroid hormone levels, and a rapid heart rate is associated with increased thyroid hormone levels.

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?

Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Cushing disease can result in female facial hair growth.

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.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible. This ulcer does not increase the client's risk for developing osteopenia, osteoporosis, or osteoarthritis.

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

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?

Under the breast 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.

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 has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown?

a 30-year-old male who sustained a spinal cord injury who is now paraplegic Risk factors for skin breakdown include immobility, incontinence, lack of sensory perception, poor nutrition and hydration, and conditions that impair blood flow. A client with a spinal cord injury has decreased mobility and sensation, so this client is at highest risk for skin breakdown. Although the clients in the other options have some impairment in their mobility, they are still ambulatory.

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 = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.

a cancerous skin lesion located on the back presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast. 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.

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?

hypoxia Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis.

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

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

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

sclera. Jaundice in light- and dark skinned people is characterized by yellow skin tones, from pale to pumpkin, particularly in the sclera, oral mucosa, 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 II. 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.

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?

"How has it changed?" Asking an open-ended question will elicit a more complete response, such as how the mole has changed for example, diameter, color, shape). The other options will not elicit the information needed to direct next priority actions. Telling the client that moles change as we age is not an appropriate response; further assessment is needed. Asking if the client knows how to check for signs of skin cancer and about when they noticed the change are close-ended questions that will not provide the information needed.

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?

67-year-old White female Fair-skinned people are at higher risk of developing skin cancer, especially those with light eyes and freckles and people who live far from the equator. However, high levels of sunlight exposure places all people at risk. Clients of African descent, Native American/First Nations heritage, Asians, and Latinos or Hispanics are generally darker-skinned people. Even though darker-skinned people are not as susceptible to skin cancers, they have a poorer prognosis because they are often diagnosed late.

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.

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?

Braden scale 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.

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

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

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution The given terms denote anatomic location, or distribution, of skin lesions over the body.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

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

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?

Document the findings in the client's record as normal 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.

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?

folliculitis Folliculitis is an infection of the follicle causing pustules and erythema. Alopecia is thinning of the hair. Scalp ringworm is a fungal infection that is scaly, red, and itchy and may cause bald patches in children; it is also known as tinea capitis.

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 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.

What is the most important focus area for the integumentary system?

UV radiation exposure 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.

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.

Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on an examination gown. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. The client may remain in a sitting position for most of the examination. If available, sunlight is best for inspecting the skin. Wear gloves when palpating any lesions because you may be exposed to drainage. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.

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

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

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

caused by aging of the skin in older adults. 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 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 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?

hypoxia Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis.

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?

pulse oximetry 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.

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 II. 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.