Assessment of the Skin, Hair, and Nails CH 26

Bleeding from vessels into tissue

a blue

Decreased skin turgor

a dehydration, sudden severe weight loss, or normal aging

Innermost layer of skin

a fat

Provides padding

a fat

Serves as insulator

a fat

Flat lesion <1 cm in diameter

a macule

To differentiate between color changes in the nail bed related to vascular supply and those from pigment disposition, what does the nurse do? a. Examine the nail plate under a Wood's light. b. Assess for thickness. c. Blanch the nail bed. d. Evaluate for lesions.

c c. Blanch the nail bed.

34. During a patient hand-off, the nurse is in- formed that the patient has xerosis of the bilat- eral lower extremities. Based on this informa- tion, the nurse expects to assess which clinical finding on the lower extremities? a. Loss of hair b. Liver spots c. Dry skin d. Paper-thin skin

c c. Dry skin

Does not have a separate blood supply

c epidermis

Melanin production

c epidermis

Synthesis of vitamins

c epidermis

Increased body hair growth on the face in the female patient

c hormone imbalance

Macules >1 cm in diameter

c patch

Fever, cellulitis

c red-erythema

With wavy borders, resembling a snake

c serpiginous

45. A young female patient reports an unusual in- crease in facial hair. Which question helps the nurse to identify the need for a genital exami- nation? a. "Have you noticed any bruising or unusual bleeding?" b. "Have you noticed any deepening of your voice quality?" c. "Are you having any trouble urinating?" d. "Does your skin seem unusually dry and flaky?

b b. "Have you noticed any deepening of your voice quality?"

A dark-skinned patient is admitted for pneu- monia. What is the most accurate method to assess for cyanosis in this patient? a. Observe for shallow and rapid respirations. b. Check the tongue and lips for a gray color c. Auscultate for decreased breath sounds throughout lung fields. d. Inspect the palms and soles for a yellow- tinged color.

b b. Check the tongue and lips for a gray color

36. It is important for the nurse to avoid taping the skin of an older adult patient due to a decrease in which integumentary factor? a. Vitamin D production b. Thickness of epidermis c. Dermal blood flow d. Epidermal permeability

b b. Thickness of epidermis

Collagen is main component

b dermis

Contains elastin

b dermis

Contains no cells

b dermis

Rich in sensory nerves

b dermis

"Heaped up" appearance of the older adult's toenail

b fungal infection

Elevated lesions <1 cm in diameter

b papule

All areas of the body involved, with no areas of normal-appearing skin

b universal

Liver disorders, chronic renal failure or increased hemolysis of red blood cells

b yellow-orange

Pregnancy (melasma) ,Addison's dis- ease

d brown

Lesions that merge with one another and appear confluent

d coalesced

Elevated patches >1 cm in diameter

d plaques

Drumstick appearance of nail shape

d prolonged hypoxia or lung cancer

47. The nurse is caring for several older adult pa- tients in a long-term care facility. The patient with which disorder has the greatest risk to develop a staphylococcal infection secondary to an ingrown toenail? a. Chronic obstructive pulmonary disease b. Hypertension Matching. c. Osteoarthritis d Diabetes mellitus

dd Diabetes mellitus

In regulating body temperature, how much evaporative water loss can occur during hot weather or exercise? a. 600 mL/day b. 900 mL/day c. 2 L/day d. 10 to 12 L/day

dd. 10 to 12 L/day

39. While obtaining a health history on a patient with a chronic skin condition, the nurse ob- serves that the patient does not make eye con- tact and keeps the affected area covered with a scarf. What is the most appropriate nursing action? a. Explain all actions and procedures to the patient. b. Explain to the patient that it is normal to be embarrassed. c. Discuss the patient's behavior with another nurse for validation. d. Explore the patient's feelings about the condition

dd. Explore the patient's feelings about the condition

35. A decreased number of active melanocytes in an older adult leads to which result? a. Decreased wound healing b. Decreased skin tone and elasticity c. Increased skin transparency d. Increased sensitivity to sun exposure

dd. Increased sensitivity to sun exposure

The health care provider has ordered diagnos- tic testing to determine whether a patient has a fungal infection of the skin. Which test does the nurse prepare the patient for? a. Shave biopsy b. Punch biopsy c. Wood's light examination d. KOH test

dd. KOH test

40. The nurse is assessing the skin of an older pa- tient. Which assessment finding needs follow- up? a. Multiple liver spots on the arms b. Xerosis on the lower extremities c. Presence of cherry hemangiomas d. One light brown macule (6.5 cm) on the right scapula

dd. One light brown macule (6.5 cm) on the right scapula

Itching

dd. Pruritus

he nurse has collected several specimens from patients who have skin conditions. Which specimen must be immediately placed on ice? a. Punch biopsy performed with sterile tech- nique for collection of a tissue piece. b. Exudate taken by sterile technique and swabbed on a bacterial culture medium. c. Aspirate taken by sterile technique, placed in a bacterial culture tube. d. Vesicle fluid taken by sterile technique and placed in a viral culture tube.

dd. Vesicle fluid taken by sterile technique and placed in a viral culture tube.

Major component of the elastic fiber

elastin

Circular

i circinate

Linear cracks in the skin

i fissure

Nodule filled with liquid or semisolid material that can't be expressed

j cyst

Lubricates the skin and reduces water loss from the skin surface

sebumb

Excessive growth of body hair or hair growth in abnormal body areas

hirsutism

Ringlike with raised borders around flat, clear centers of normal skin

a annular

The nurse is interviewing a patient who has come to the walk-in clinic and observes the patient has matted hair, body odor, and soiled clothes. Which conditions does the nurse as- sess for that could be contributing to the pa- tient's overall hygiene? (Select all that apply.) a. Range of motion and strength to perform self-care b. Access to shower facilities and a laundry c. Financial ability to pay water and heating bills d. Patient's perception of how he or she ap- pears to others e. Diabetes mellitus or hypertension f. Intactness of sensory functions (i.e., sight, smell) g. Patient's knowledge (or memory) of how to perform hygiene care

a, b, c, d, f, g a. Range of motion and strength to perform self-care b. Access to shower facilities and a laundry c. Financial ability to pay water and heating bills d. Patient's perception of how he or she ap- pears to others f. Intactness of sensory functions (i.e., sight, smell) g. Patient's knowledge (or memory) of how to perform hygiene

33. Age-related changes in the integumentary sys- tem include a decrease in which factors? (Select all that apply.) a. Vitamin D production b. Thickness of epidermis c. Thickness of dermis d. Epidermal permeability e. Dermal blood flow

a, b, c, e a. Vitamin D production b. Thickness of epidermis c. Thickness of dermis e. Dermal blood flow

A patient reports a rash that itches, but denies fever, shortness of breath, or other symptoms. Which questions does the nurse ask to help determine if the patient is having an allergic reaction? (Select all that apply.) a. "Are you taking any new medications?" b. "Have you been using any different soaps or lotions?" c. "Is your skin unusually dry or flaky?" d. "Have you been exposed to any new clean- ing solutions?" e. "Have you noticed any new bruises or brownish discolorations?" f. "Have you had any changes in your diet?"

a, b, d, f a. "Are you taking any new medications?" b. "Have you been using any different soaps or lotions?" d. "Have you been exposed to any new clean- ing solutions?" f. "Have you had any changes in your diet?"

78. The nurse is caring for a patient who had an excisional biopsy for a skin lesion. What does the post-procedural care for this patient in- clude? (Select all that apply.) a. Monitor the biopsy site for bleeding. b. Instruct the patient to keep the site clean and dry for at least 24 hours. c. Teach the patient to clean the site daily af- ter the dressing is removed. d. Remove dried blood or crusts with diluted hydrogen peroxide. e. Instruct the patient to report any redness or excessive drainage. f. Advise the patient that the sutures will be removed in 7 to 10 days.

a,c,e,f a. Monitor the biopsy site for bleeding. c. Teach the patient to clean the site daily af- ter the dressing is removed. e. Instruct the patient to report any redness or excessive drainage. f. Advise the patient that the sutures will be removed in 7 to 10 days.

The health care provider instructs the nurse to prepare a light-skinned patient for examina- tion, which includes evaluation of skin pig- ment changes. Which piece of equipment does the nurse obtain to assist the provider with this examination? AWood's light B Glass slide C Biopsy tray D Non-fluorescent light

aAWood's light

the nurse is performing a physical exam on a patient and observes a dark asymmetrical le- sion on the patient's back. The patient states, "I can't see back there and I don't know how long it has been there." What is the most important intervention for this patient? a. Encourage the patient to make an appoint- ment with a dermatologist. b. Teach the patient how to do a total skin self-evaluation. c. Instruct the patient on self-care measures, such as use of sunscreen. d. Obtain an order for a fungal culture and take a fungal specimen.

aa. Encourage the patient to make an appoint- ment with a dermatologist.

The nursing student must perform a skin as- sessment on an older adult patient and observe for signs of skin breakdown. What does the student do to meet the clinical objective and demonstrate good time-management skills? a. Examine the skin while bathing or assist the patient with hygiene. b. Complete the assessment before the end of the clinical experience. c. Check to see if the primary nurse has al- ready completed the assessment. d. Perform the examination when the patient willingly consents and agrees.

aa. Examine the skin while bathing or assist the patient with hygiene.

A patient has a history of mild congestive heart failure. The nurse is assessing the patient's low- er extremities; the skin is tight and shiny, but the patient currently denies pain or distress, saying "Oh, my legs just get like that." How does the nurse interpret these findings? a. Fluid retention and edema b. Early signs of poor circulation c. Early stage of infection d. Normal for this patient

aa. Fluid retention and edema

53. The nurse is assessing a patient who is African American with very dark skin. Which tech- nique does the nurse use to assess the health of the nail? a. Gently squeeze the end of the finger, exert downward pressure, then release the pres- sure. b. Obtain a color chart to identify the normal color of nails for the dark-skinned patient. c. Observe the nail bed for a pale pink color and a shiny, smooth surface. d. Soak the fingertips in warm water, then gently push back the cuticle.

aa. Gently squeeze the end of the finger, exert downward pressure, then release the pres- sure.

32. The nurse is performing a skin assessment on a patient and notes an area on the forearm that feels hard or "woody." What does the nurse in- terpret this physical finding as? a. Inflammation b. Subcutaneous fat c. Psoriasis d. Skin cancer

aa. Inflammation

the nurse is preparing patient education mate- rial about healthy skin. What is the single most important preventive health behavior the nurse promotes? a. Limit continuous sun exposure. B. Drink plenty of water. C. Practice good skin hygiene. D. Eat a well-balanced diet.

aa. Limit continuous sun exposure.

The nurse is caring for an older adult patient with very dark skin. The patient has a low he- moglobin and hematocrit. How does the nurse assess for pallor in this patient? a. Observe the mucous membranes for an ash-gray color. b. Use indirect and low fluorescent lighting. c. Gently push on the skin and watch for blanching. d. Inspect the conjunctivae for a yellowish color.

aa. Observe the mucous membranes for an ash-gray color

37. In an older adult, decreased vitamin D produc- tion increases the patient's susceptibility to which condition? a. Osteomalacia b. Osteodystrophy c. Hypothermia d. Dry skin

aa. Osteomalacia

13. A patient with a history of congestive heart failure goes to the outpatient clinic for a follow-up appointment. How does the nurse assess for dependent edema in this patient? a. Palpate the dorsum of the foot or the me- dial ankle. b. Weigh the patient and compare to the baseline weight. c. Check the patient's buttocks or lower back. d. Ask the patient about intake and output.

aa. Palpate the dorsum of the foot or the me- dial ankle.

29. A patient is being referred to a dermatologist for evaluation of a rash of unknown origin. The patient has trouble articulating specific information because of "nervousness." Which questions does the nurse use to help the pa- tient practice for the specialist appointment? (Select all that apply.) a. "Why do you have the rash?" b. "When did you first notice the rash?" c. "Where on the body did the rash first start?" d. "How do you feel about the skin rash?" e. "Are you having an itching or burning sen- sation?" f. "What makes the problem better or worse?" g. "Have you been having fever or sore throat?"

b, c, e, f, g b. "When did you first notice the rash?" c. "Where on the body did the rash first start?" e. "Are you having an itching or burning sen- sation?" f. "What makes the problem better or worse?" g. "Have you been having fever or sore throat?

The nurse is caring for a patient who sustained trauma and blood loss. The patient is alert and anxious, blood pressure is low, and the heart rate is high. Which skin characteristics are most likely to manifest during impending shock? a. Dry, flushed appearance b. Cool, pale, moist skin c. Bluish color that blanches with pressure d. Poor turgor with a rough texture

bb. Cool, pale, moist skin

31. The nurse is caring for a very dark-skinned patient who has high risk for thrombocytope- nia. Which area of the patient's body is the best place to check for petechiae? a. Anterior chest b. Oral mucosa c. Palmar surface d. Periorbital area

bb. Oral mucosa

A patient reports a history of chronic liver problems; liver enzyme tests and bilirubin results are pending. In order to assess for jaun- dice, where is the best place for the nurse to look for a yellowish discoloration? a. Hard palate b. Sclera c. Palms d. Conjunctivae

bb. Sclera

38. In caring for an older adult patient, the room may need to be kept warmer because of a de- crease in which integumentary factor? a. Sebum production b. Subcutaneous fat layer c. Thickness of epidermis d. Number of active melanocytes

bb. Subcutaneous fat layer

The nurse is caring for a patient who is sev- eral days postoperative. The nursing assistant reports that the patient's linens were changed, but are wet again. The nurse notes that the patient's skin is excessively warm and moist. What is the nurse's priority action? a. Initiate intake and output b. Take the patient's temperature c. Direct the nursing assistant to change the linens d. Help the patient with hygiene

bb. Take the patient's temperature

The nurse is collecting a superficial specimen for a suspected fungal infection from a pa- tient's groin area. What is the correct technique to obtain this specimen? a. Obtain a small sample of tissue by using a biopsy needle. b. Express exudate from a lesion and use a sterile swab to collect the fluid. c. Gently scrape scales with a tongue blade into a clean container. d. Aspirate fluid from the lesion using sterile technique.

c. Gently scrape scales with a tongue blade into a clean container.

A thin and malnourished patient requires emergency abdominal surgery. After the op- eration, in order to promote wound healing, what does the nurse encourage? A High-calorie diet B. Low-sodium and low-carbohydrate C. diet High-quality protein diet D.Low-fat diet with vitamin supplements

cC. diet High-quality protein diet

77. A patient is scheduled to have a punch biopsy for a lesion on the mid-back. What does the nurse tell the patient about the procedure? a. There will be a small scar similar to any surgical procedure. b. The surgeon uses a scalpel to punch through the lesion. c. A local anesthetic is used and it causes a temporary burning sensation. d. The physician uses a lens that punches the skin to reveal the shape of the lesion.

cc. A local anesthetic is used and it causes a temporary burning sensation.

14. The nurse is assessing the skin of an older adult patient who is at risk for dehydration due to excessive vomiting. The skin appears dry and loose. Where is the best site for the nurse to check skin turgor on this patient? a. Facial cheek b. Upper arm c. Anterior chest d. Mid-thigh

cc. Anterior chest

The nurse is assessing a patient's skin and notes a slightly darkened area over the left ankle. The patient denies pain, but reports a recent prob- lem with the area. Based on the skin appear- ance and the patient's report, what does the nurse do next? a. Ask the patient if there was a serious and deep burn to the area. b. Observe the area for scar tissue. c. Ask the patient if there was an inflamma- tion to the area. d. Take a scraping of the skin for culture.

cc. Ask the patient if there was an inflamma- tion to the area.

12. A patient is at risk for hypovolemia. The nurse assesses this patient's skin using which assess- ment technique? a. Brush the skin surface and observe for flaking. b. Push on the skin and observe for blanch- ing. c. Gently pinch the skin on the chest and ob- serve for tenting. d. Push on the skin over the tibia and observe for depth of indentation.

cc. Gently pinch the skin on the chest and ob- serve for tenting.

46. Which statement about dandruff is true? a. Dandruff flakes are caused by a dry scalp. b. Dandruff is merely a cosmetic problem. c. Severe dandruff could cause hair loss. d. Brushing your hair every day prevents dandruff.

cc. Severe dandruff could cause hair loss.

the nurse is taking a medication history of a patient and performing a physical assessment on the skin. During the assessment the nurse notes that the skin is thin, fragile, and papery. The nurse specifically asks if the patient takes which type of medication? a. Anticoagulants b. Oral hypoglycemics c. Steroids d. Herbal preparations

cc. Steroids

54. A patient reports a subjective sensation of pain and tenderness "because my arthritis is flaring up." In order to assess for inflammation, what does the nurse do? a. Place the hand just above the area and feel for radiant warmth. b. Use fingertips to gently depress tissue area and then release and observe. c. Use the back of the hand to palpate the area for warmth. d. Using the palmar surface of the hand, make a circular motion over the area.

cc. Use the back of the hand to palpate the area for warmth.

Skin becomes thickened

lichenified

Several lesions grouped together

e clustered

Elevated, marble-like lesions >1 cm wide and deep

e nodule

Small, reddish-purple lesions that do not fade or blanch when pressure is applied

e petechiae

Vasoconstriction,sudden emotional upset

e white

Widespread, involving most of the body with intervening areas of normal skin

f diffuse

Large bruised areas of hemorrhage; vary in size

f ecchymoses

Blister <1 cm in diameter filled with clear fluid

f vesicle

Occurring in a straight line

g linear

Fine, flat rash

g macular

Vesicle filled with cloudy fluid

g pustule

well-defined with sharp borders

h circumscribed

Elevated, irregular, and transient areas of dermal edema

h wheals

Raised rash

papular

Indicates amount of skin elasticity

turgor