PrepU Chapter 14 Skin, Hair, Nails

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

True

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

Under the breast

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.

ashen

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.

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.

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

pulse oximetry

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? Unbroken but red in color Ulceration resembling a crater Exposure of subcutaneous tissue and muscle Broken with the presence of a blister

Broken with the presence of a blister A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.

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? Lower the head of bed and pull the client up with both arms. Place the client in trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client. Push the client toward the head of the bed to prevent back injury.

Call for help and use the draw sheet to move the client. Friction and shear forces are risk factors for developing pressure ulcers. The nurse should ask for help and use a draw sheet to avoid shearing forces. Pulling the client up in bed and allowing the client to slide in bed create friction and shear forces. Pushing the client also creates shearing forces.

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

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

Fainting Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

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: plaque. macule. papule. patch.

Plaque Plaques are elevated, palpable, solid masses greater than 0.5 cm and may be coalesced papules with a flat top. Papules are also elevated, palpable, sold masses, but are smaller than 0.5 cm. Macules and patches are small, flat, nonpalpable skin color changes.

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

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.

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

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

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.

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

Moisture Activity Nutrition

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. Ask the client to remove only his shirt Have the client stand for the entire examination Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed

Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing? anemia liver disease advanced lung disease congestive heart failure

advanced lung disease Central cyanosis is a bluish-tint to the lips, tongue, and oral mucosa. Causes of central cyanosis include advanced lung disease. Pallor is associated with anemia. Jaundice is associated with liver disease. Cyanosis in congestive heart failure is usually peripheral, reflecting decreased blood flow.

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

high

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

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.

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.

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