ch 24 assessment of skin, hair, and nails
While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include?
"Administration of local anesthetic agents may cause burning."
The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of the extremities is the nurse specifically concerned about?
Marked dependent pitting edema
Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area?
Five clustered circumscribed lesions on the chest
An older immobile client has "sunk" to the bottom of the bed. What does the nurse do first?
Get help and lift the client.
An older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response?
How is this affecting you?"
The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching?
I have been working in my garden for several hours every day.
The nurse is instructing a client on skin and sun protection. Which statement by the client indicates a need for further teaching?
I use a tanning bed to avoid the sun's harmful rays.
When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider?
A multicolored lesion is present on the client's thigh.
Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN?
Administer an antihistamine to a client who is describing pruritus.
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN?
Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road
A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity does the nurse assign to an LPN/LVN working with this client?
Apply an antibiotic ointment and place a sterile dressing on the incision.
Which method does the nurse use to assess skin lesions for cancer?
Asymmetry, border, color, diameter, evolving
The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term-care client who has areas of skin breakdown in the skinfolds and the perineal area. Which intervention is best for the RN to delegate to the nursing assistant?
Bathe the client, and apply a protective barrier to skinfolds and perineum.
The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client?
Body image counseling
The nurse notices yellowing at the corners of the sclera in an African-American client admitted for hepatitis. What does the nurse do next?
Checks the oral mucosa
The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action does the nurse take first?
Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.
Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon?
Presence of one of the "ABCDE" features
The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition?
Psoriasis
During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response?
Reddish blue area on the calf
Which skin condition will the emergency department nurse assess first?
pitting edema
