CH 9 Integumentary System PrepU

Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what? A. Psoriasis B. Varicella C. Acne D. Herpes simplex

Acne

The student nurse learns that examining the skin can do all of the following except? A. Reveal overhydration B. Identify physical abuse C. Allow early identification of neurologic deficits D. Allow early identification of potentially cancerous lesions

Allow early identification of neurologic deficits

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma? A. Asymmetrical shape B. Diameter less than 1/8 of an inch C. Color is uniform D. Borders well demarcated

Asymmetrical shape

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? A. Local irritation can cause damage to the nail bed B. Can be caused by an underlying systemic illness C. Abnormalities may be a sign of poor hygiene D. May affect a person's body image negatively

Can be caused by an underlying systemic illness

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? A. Basal cell carcinoma B. Lupus erythematosus C. Iron deficiency anemia D. Cushing's disease

Cushing's disease

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? A. Inadequate circulation B. Decreased subcutaneous tissue C. Continuous trauma D. Excessive collagen formation

Excessive collagen formation

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? A. Diabetes mellitus B. Hypothyroidism C. Crohns disease D. Liver disease

Hypothyroidism

Which of the following assessment findings most likely constitutes a secondary skin lesion? A. Facial acne B. Keloid formation at the site of an old incision C. Facial lesions associated with herpes simplex D. Psoriasis

Keloid formation at the site of an old incision

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? A. Hepatic failure B. Respiratory failure C. Renal failure D. Cardiovascular failure

Renal failure

Squamous cell carcinoma is associated with A. overall amount of sun exposure. B. an increase in the rates of melanoma. C. precursor lesions. D. intermittent exposure to ultraviolet rays.

overall amount of sun exposure.

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? A. "Does anyone else in your family have a rash like this?" B. "Are you allergic to foods, medications, or other substances?" C. "Have you ever had a rash like this before?" D. "What have you been doing to control the itching?"

"Are you allergic to foods, medications, or other substances?"

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.) - Size - Depth - Location - Other lesions on body - Texture

- Size - Location - Texture

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? A. Subcutaneous layer B. Epidermis C. Connective layer D. Dermis

Dermis

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A. Linear B. Annular C. Confluent D. Discrete

Discrete

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? A. Inspect the area B. Move on to next body system C. Ask further questions D. Document the statement

Inspect the area

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what? A. Neurofibromatosis B. Central cyanosis C. Reynaud disease D. Peripheral cyanosis

Peripheral cyanosis

Which technique should the nurse use to properly assess a client's skin turgor? A. Palpate the skin on the sternum to determine its flexibility B. Palpate the skin around the umbilicus to assess for intactness C. Pinch the skin on the abdomen and observe for color changes D. Pinch the skin on the sternum and observe its return to the original shape.

Pinch the skin on the sternum and observe its return to the original shape.

Which technique should the nurse use to properly assess a client's skin turgor? A. Palpate the skin around the umbilicus to assess for intactness B. Palpate the skin on the sternum to determine its flexibility C. Pinch the skin over the clavicle and observe its return to the original shape D. Pinch the skin on the abdomen and observe for color changes

Pinch the skin over the clavicle and observe its return to the original shape

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? A. Cherry angioma B. Cutaneous horn C. Pressure ulcer D. Seborrheic keratosis

Pressure ulcer

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? A. Sweat glands B. Sebum production C. Squamous cells D. Subcutaneous tissue

Sebum production

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? A. The client has chronic hypoxia B. The client has COPD C. The client has melanoma D. The client has asthma

The client has chronic hypoxia

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A. The client's history of integumentary disorders B. The client's ability to change position C. The client's current medication regimen D. The pigmentation of the client's skin

The client's ability to change position

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings? A. The patient may have a cognitive deficit. B. The patient may have peripheral vascular disease. C. The patient may have been abused. D. The patient is elderly.

The patient may have been abused

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? A. There is a nonblanching reddened area on the client's coccyx region. B. There is noticeable bruising on and around the client's coccyx region. C. There is a generalized rash on the client's lower back and buttocks. D. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx.

There is a nonblanching reddened area on the client's coccyx region.

A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following? A. Thin B. Thick C. Flushed D. Pale

Thin

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? A. Vitiligo B. Striae C. Albinism D. Angiomas

Vitiligo

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? A. When palpating the client's hair B. When palpating the client's nail beds for texture and capillary refill C. When palpating lesions on the client's skin D. When palpating the texture of the client's skin

When palpating lesions on the client's skin

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 A. stage IV. B. stage I. C. stage II. D. stage III.

stage II