Assessment Ch. 14 / Skin, Hair, Nails
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed? (Picture of lesion all the way down to muscle)
Osteomyelitis
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 client's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the client's risk for pressure sore development is:
Mild risk
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?
Psoriasis
A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?
"It will take about 6 months to totally replace a fingernail"
The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as:
Vitiligo
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
3
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?
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 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
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
A client has a small but elevated, solid, palpable, 0.5 cm mass on the forearm. Which diagram should the nurse use to explain this mass to the client?
smallest elevation picture
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?
"Do you feel anxious at times?"
Hair follicles, sebaceous glands, and sweat glands originate from the
Dermis
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution
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?"
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
Connecting the skin to underlying structures is/are the
subcutaneous tissue
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
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?
Notched border Diameter greater than 6mm Asymmetry
The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?
A neuropathic ulcer can develop without feeding it
A client comes to the clinic reporting red "itchy" skin. The nurse should assess the client for which of the following causes of pruritus? Select all that apply.
Aging Allergies New medications Liver dysfunction
The student nurse learns that examining the skin can do all of the following except?
Allow early identification of neurologic deficits
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
Areola of the breast
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure
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
A nurse observes yellow, thick, crumbling toenails on a new client. The nurse suspects which of the following conditions?
Fungal infection
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
A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?
Increased body and facial hair
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
Intact, firm skin with redness Ulceration involving the dermis Full thickness skin loss Necrosis with damage to underlying muscle
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Keloid formation at the site of an old incision
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
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?
Skin warm and dry to the touch
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
Short, pale, and fine hair that is present over much of the body is termed
Vellus
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
Vesicles
A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
skin with large bump (picture)
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for:
symptoms of stress
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Woods light
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Psoriasis
What is the most important focus area for the integumentary system?
UV radiation exposure
