CH 55 Med Surg Assessment of integumentary Function
a patient has a serum bilirubin concentration of 3 mg/100 mL. which will the nurse observe when performing a skin assessment on this patient?
jaundice
the epidermis is composed of three types of cells: __, __, and __?
keratinocytes merkel cells langerhans cells
a patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. how will the nurse document this finding?
lichenification
alopecia
loss of hair from any cause
describe how the production of melanin is controlled?
melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte stimulating hormone
the nurse observes an African American patient with a large hypertrophied area of scar tissue on the left ear lobe. which does the nurse document this finding as?
Keloid
the nurse is applying a cold towel to a patient neck to reduce body heat. how will the nurse determine that the heat is reduced?
conduction
hypopigmentation
decrease in the melanin of the skin, resulting in a loss of pigmentation
langerhans cells
dendritic clear cells in the epidermis that carry surface receptors from immunoglobulin and complement and that are active participants in delayed hypersensitivity of the skin
when assessing the skin of an older adult, which major age-related changes are seen in the skin?
dryness wrinkling uneven pigmentation various proliferative lesions cellular changes associated with aging including a thinning at the junction of the dermis and epidermis
there are three layers of the skin: __, __, and __?
epidermis dermis subcutaneous tissue
sebum
fatty secretion of the sebaceous glands
sebaceous glands
glands that exist within the epidermis and secrete sebum to keep the skin soft and pliable
a patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. there is no yellowing of the sclera or mucous membranes. which question would be most appropriate to ask the patient to identify a potential cause of the skin discoloration?
have you been eating a large amount of carotene-rich foods
the nurse is assisting with the collection of a Tzanck smear. which is the suspected diagnosis of the patient?
herpes zoster
the nurse should know that clubbing of the nails is usually an indicator of __?
hypoxia
hyperpigmentation
increase in the melanin of the skin, resulting in an increase in pigmentation
the epidermis is almost completely replaced every __?
2 to 3 weeks
the nurse is caring for an adult patient with a body temperature within normal range. which is the approximate insensible water loss per day in this patient?
600 mL/day
skin needs to be exposed to sunlight to manufacture vitamin __?
D
vitiligo
a localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches
the subcutaneous tissue, which is primarily composed of __ tissue, has a major role in __ regulation?
adipose temperature
the term used to describe hair loss is __ ?
alopecia
keratin
an insoluble fibrous protein that forms the outer layer of the skin
keratin
an insoluble, fibrous protein that forms the outer skin layer
dermatosis
any abnormal skin condition
keratinocytes
arising from the innermost layer of the epidermis, synthesize the insoluble protein, keratin
echymosis
bleeding into the skin and tissue, initially evidenced by varied color (ex purple, black) that gradually fades to green, yellow, or brown over time
the nurse is assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. which disorder does the nurse identify correlates with this assessment finding?
carbon monoxide poisoning
merkel cells
cells of the epidermis that play a role in transmission of sensory messages
melanocytes
cells of the skin that produce melanin
a patient is visiting the health care provider to determine what type of allergy is causing a rash. which type of testing will be appropriate in order to determine the cause of this finding?
patch test
petechiae
pinpoint red spots that appear on the skin as a result of blood leakage into the skin
the nurse is assessing a patient with a primary skin lesion called a macule. which does the nurse identify is a clinical example of this lesion?
port-wine stains
the nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand of a patient that bleed when picked off. which skin disorder correlates with this assessment finding?
psoriasis
the nurser is assessing the fingernails of a patient at the clinic. the nurse observes pitting on the surface of the nail. which disorder is this finding indicative of?
psoriasis
the nurse is assessing a patient with risk factors related to human immune deficiency virus (HIV). which assessment finding does the nurse identify as a manifestation of the disease?
purplish cutaneous lesions
__, __, and __ are the major physical processes involved in loss of heat from the body to the environment?
radiation conduction convection
telangiectasia
red marks on the skin caused by distention of the superficial blood vessels
erythema
redness of the skin caused by congestion of the capillaries
erythema
redness of the skin, caused by dilation of the capillaries due to injury, irritation, inflammation, or various skin conditions
jaundice can be first observed by examining the __ and __?
sclera mucous membrane
__ and __ are two types of skin glands?
sebaceous sweat
hirsutism
the condition of having excessive hair growth
describe what function the hair of the skin serves?
the hair of the skin provides thermal insulation in mammals. this function is enhanced during cold or fright by piloerection, caused by contraction of the tiny erector muscles attached to the hair follicle
what is the function of the receptors endings of the nerves in the skin?
the receptors endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. they sense temperature, pain, light touch, and pressure
the nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. how will the nurse determine from skin color change that shock may be present?
the skin is ashen gray and dull
melanin
the substance responsible for coloration of the skin
wood light
ultraviolet light used for diagnosing skin conditions
rete ridges
undulation and furrows that appear at the lower edge of the epidermis at the dermal junction where these two skin layers are cemented together
telangiectasias
vascular structures; red marks on the skin caused by distention of the superficial blood vessels
the nurse assesses a patient and observes a herpes simplex/zoster skin lesion. how will the nurse document this lesion?
vesicle