PrepU: Chapter 14 Skin, Hair, and Nails

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken with the presence of a blister.

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

Call for help and use the draw sheet to move the client.

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. The client denies the use of any new shampoos, or other hair care products; no new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism.

The RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed.

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.

Which of the following is an important function of the skin?

Synthesis of vitamin D.

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.

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.

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

Dermis.

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

Risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

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.

A nurse implements which skin assessment to determine the presence of dehydration in a client?

Skin turgor.

A decrease in oxyhemoglobin will result in documentation of pallor.

True.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

Underarms.

When inspecting the hair, what would the nurse note?

-Color. -Condition of hair shaft. -Hair shafts that are shiny.

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

Ashen.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. What is an "ABCDE" characteristic of malignant melanoma?

Asymmetrical shape.

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes.

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits.

Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what?

Acne.

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

Carotene.

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?

Cushing's disease.

A nurse cares for a client of Asian descent and notices that the client produces no body odor. What is an appropriate action by the nurse?

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

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.

Squamous cell carcinoma is associated with

Overall amount of sun exposure.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?

Peripheral cyanosis.

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

areola of the breast.

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?

A sebaceous cyst.