Adult Heath 3

secondary lesions

description of skin disease in terms of changes in the appearance of the primary lesion theres changes occur with the progression of an underlying disease or in response to a topical or systemic therapeutic intervention

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 mm Hg B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food or water since 9:00 p.m. last nigh

C,D

hirsutism

Abnormal growth of body hair especially on the face chest and linea alba of the abdomen of women

nits

Lice eggs

Who hates this shit

Me

Decreased epidermal mitotic homeostasis

Skin hyperplasia and skin cancers (especially in sun exposed spots)

dandruff

an accumulation of patchy or defuse white or gray scales on the scalp

turgor

if you dont know this ur an idiot

Benign proliferation of capillaries

Cherry hemangiomas teach patient that these are benign

Decreased number of active melanocytes in follicles

Gradual loss of hair color (graying) Inform patients that hair color loss can occur at any age

rete pegs

The fingers of epidermal tissue that project into the dermis.

Acute paronychia

(inflammation of the skin around the nail) often occurs with a torn cuticle or an ingrown toenail

How many liters of fluid are lost in a day due to sweat?

10 to 12 liters lost a day in sweat

In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

A

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt."

A

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pinprick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

A

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A,C,D,E

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

A,C,D,E

lichenified

ABNORMAL THICKENING OF THE SKIN TO A LEATHERY APPEARANCE CAN OCCUR IN PATIENTS WITH CHRONIC DERMATITIS BECAUSE OF THEIR CONTINUAL RUBBING OF THE AREA TO RELIEVE THE ITCHING

dystrophic

Abnormal in appearance

pruritis

An uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body.

The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 a.m. as originally prescribed. B. Adjust the administration time to be given at 10:00 a.m. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B

Which assessment data regarding a lesion found on a 39-year-old client who uses a tanning bed requires nursing intervention? Select all that apply. A. Symmetrical and light pink B. Brownish-purple with irregular borders C. Changed in shape since last appointment D. 8 mm wide and described as itching often E. Regular border with fixed size and elevation

B,C,D

Keratinocytes

Basal skin cells attached to the basement membrane of the epidermidis that undergo cell division and differentiation to continuously renew skin tissue integrity and maintain optimal barrier function. As basal cells divide, keratinocytes are pushed upwards and flattened to form the stratified layers of the epithelium MALPIGHIAN LAYERS

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image

C

thickening of the nails

toenails thicken and may overhang the toes use fingernails to assess capillary refill. cut toenails straight across do not use nail appearances alone to assess for fungal infection Assess skin next to the nail to determine weather the think nail is irritating it.

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

C,D,E

Hyperplasia of melanocyte activity (especially in sun exposed areas)

Changes in pigmentation (liver spots) Teach patient to keep track of pigmented lesions Teach which changes should be evaluated for malignancy

How will the nurse describe a shave biopsy to a client? A. "A scalpel will be used to remove a deep sample of skin." B. "A small plug of tissue will be removed with a circular cutting instrument." C. "A deep specimen of skin will be taken, and the area will be sutured closed." D. "A razor blade will be gently moved across the skin's surface to obtain a sample."

D

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

D

Decreased immune system cells

Decreased inflammatory response do not rely on degree of redness and swelling to correlate with the severity of skin injury or localized infection

Decreased Cell Divison

Delayed wound healing, avoid skin trauma and protect open areas

Lunula

whitish, half-moon shape at the base of the nail

primary lesions

In describing skin disease, the initial reaction to a problem that alters one of the structural components of the skin.

(Hair) Decreased number of hair follicles and growth rate

Increased hair thinning suggest wearing hats to prevent heat loss in cold weather and to prevent sunburn

(Nails) Decreased rate or growth

Increased rate of fungal infection inspect the nails of all older adults, teach patients to keep feet clean and dry

Decreased Vasomotor responsiveness

Increased risk for heat stroke and hypothermia Teach patients to dress from the environmental temperatures

(Subcutaneous Layer) Thinning subcutaneous layer

Increased risk for hypothermia Increased risk for pressure injury Teach patient to dress warmly in cold weather help patients confined to bed or chairs changed positions every 2 hours

Decreased melanocyte activity

Increased risk for sunburn teach patients to wear hats, sunscreen (minimum of SPF30) and protective clothing teach patient to avoid sun exposure from 10am-4pm

Increased epidermal permeability

Increased risk of irritation Teach patient how to avoid exposure to skin irritants

Decreased Vitamin D production

Increased risk of osteomalacia Urge patients to take a multiple vitamin or a calcium supplement with vitamin D

Decreased eccrine and apocrine gland activity

Increased susceptibility to dry skin Urge patients to used soaps with high fat content Teach patients to avoid frequent bathing with hot water. Teach patients to apply moisturizer after bathing while skin is still moist. Decreased perspiration with decreased cooling effect Do not sue sweat production as an indicator of hyperthermia

(Dermis) Decreased dermal blood flow

Increased susceptibility to dry skin. Teach patients to apply moisturizers when the skin is still moist and to avoid agents that promote dry skin

Chronic Paronychia

Inflammation of the skin around the nail that persists for months.

Decreased nail bed blood flow

Longitudinal nail ridges assess oral mucosa for cyanosis Nails are not the best source for cyanosis or jaundice

Decreased dermal thickness

Paper-thin, transparent skin with an increased susceptibility to trauma Handle patients gently and avoid the use of tape or tight dressings Use lift sheets when positions patients

Reduced number and function of nerve endings.

Reduced sensory perception tell patients to use a bath thermometer and lower the water heater temp to prevent scalds

macular

Referring to a macula, a discolored spot on the skin that is not raised above the surface.

papular

Referring to a papule, a small, solid elevation of the skin.

Decreased Epidermis Thickness (age related changes)

Skin transparency and fragility Handle patients carefully to reduce skin friction and shear. Assess for excessive dryness or moisture. Teach those with excessive dryness to limit warm baths to 3 times weekly and to use skin emollient- Avoid taping the skin

Bioburden

The number of viable microorganisms in or on an object or surface or the organic material on a surface or object before decontamination or sterilization.

keratin

The protein produced by keratinocytes makes the outer most skin layer waterproof

dermal papillae

a fingerlike projection of the dermis that may contain blood capillaries or Meissner corpuscles (of touch) Anchor the epidermis to the dermis.

ground substance

a lubricant composed of protein in sugar groups that surround the dermal cells and fibers and contributes to the skins normal supplements and turgor

sebum

a mildly bacteriostatic, fat containing substances produced by the sebaceous glands. Sebum lubricates the skin and reduces water loss from the skin surface.

Flattening of the dermal epidermal junction

increased risk for shearing forces, resulting in blisters, purpura, skin tears, and pressure related injury. Never pull of drag patients, help patients confined to be or chairs change positions at least every 2 hours avoid using adhesives unless necessary, and use care when removing adhesive wound dressings, encourage a well balanced diet with protein and adequate hydration

(Glands) Decreased sebum production

increased size of nasal pores, large comedones Teach patient to squeeze the pores or comedones to prevent skin trauma

ecchymoses

larger blue or purplish patches on the skin (bruises) results in small hemorrhages, these bruises are larger than peteguie

petechiae

pinpoint purple or red spots from minute hemorrhages under the skin

purpura

purple patches on the skin that may be caused by blood disorders, vascular abnormalities or trauma

stratum corneum

the outermost HORNIEST layer of the skin

taut

tightly stretched