ch. 14 integumentary
Which statement by a client about the skin needs validation by the collection of objective data by the nurse?
"My feet hurt and are always cold to the touch"
the nurse recognizes that which client is at greatest risk for the development of skin cancer?
55 y/o male who lived in cali for 20 years
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply.
Asymmetrical, Change in size, Itching, Bleeding of a mole
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.
Disturbed Body Image, anxiety, and ineffective Individual Coping
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.
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
A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?
Pinch a fold of skin on the client's forearm. To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the client's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.
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 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.
A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?
Seborrheic keratosis This is a typical description for seborrheic keratosis. The stuck on appearance and rough wart-like texture are key features. These lesions often produce greasy scales when scratched with a fingernail, which further helps to distinguish them. Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish them to prevent unnecessary biopsy; however, it is important to consider biopsy whenever there is any doubt.
How should the nurse palpate the skin of a client to assess its texture?
Touch with the palmar surface of the three middle fingers. these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness
The student nurse learns that examining the skin can do all of the following except?
allow early identification of neurological deficits
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
ashen Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)
asymmetry, notched border, diameter greater than 6mm
While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is
blue/green
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?
braden scale Identifying risk for skin breakdown is especially important in hospitalized or inactive clients. Many health care facilities use the Braden Scale to assess risk in clients, with interventions based on the total score.
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
dermis The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.
A client with a zosteriform rash has a rash that
distributed along a dermatome
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
distribution The given terms denote anatomic location, or distribution, of skin lesions over the body.
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
document as normal
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
fainting/ arterial insufficiency
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 Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.
The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of
great degree of cyanosis
A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?
hx of smoking
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
hypothyriodism
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
impetigo
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
An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)
location, size, texture
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 Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma.
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.
pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin. ** Changing position frequently will assist in preventing pressure sores.
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 This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.
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?
pulse ox
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 touch
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
spooning Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on body sites with heavy sun exposure.
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 2: broken with a presence of a blister, resembles an erosion A stage II pressure ulcer is a partial-thickness loss of dermis presenting as either a shallow, open ulcer with a red-pink wound bed, without slough or as an intact or open/ruptured, serum-filled blister. The ulcer is shiny or dry, and there is no slough or bruising. A stage I pressure ulcer presents with intact skin with nonblanchable redness. A stage III ulcer involves full-thickness tissue loss, and subcutaneous fat may be visible. A stage IV ulcer exposes bone, tendon, or muscle.
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 In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
underarms The apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress. This type of gland does not secret on locations identified by the other options.
Short, pale, and fine hair that is present over much of the body is termed
vellus (peach fuzz)
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. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.
