Ch.11 Skin, Hair, and Nails

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 - Aids in maintaining body temperature - Protects against damage to the body from sunlight - Helps make vitamin D in the body

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

- intact, firm skin with redness - ulceration involving the dermis - full-thickness skin loss - necrosis with damage to underlying muscle

Which of the following terms is used to describe the arrangement of skin lesions?

Annular

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?

Cushing's disease

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D.

The nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined.

A client's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the client's risk for pressure sore development is:

Mild risk

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?

Nail problems can be caused by an underlying systemic illness

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

caused by aging of the skin in older adults.

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis

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

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

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a

papule

Short, pale, and fine hair that is present over much of the body is termed

vellus

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer

The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C?

color

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

"Do you take steroid medications on a regular basis?"

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

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 oximetry

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

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?

History of cigarette smoking

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

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 the findings in the client's record as normal

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?

The client's ability to change position

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days

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?

There is a non-blanching reddened area on the client's coccyx region.

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

stage II.

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

Acne

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

Which of the following findings related to hair would the nurse most likely assess in an older adult female client?

Terminal hair growth on chin

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

"These are considered a normal age-related change in the skin."

Assessment of a client's nails reveals Beau's lines. The nurse interprets this finding as indicating which of the following?

Acute illness

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

Alcoholism

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

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

Broken with the presence of a blister

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

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?

Excessive collagen formation

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?

Hypoxia

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?

It is likely to be related to her lupus.

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

Melasma generally resolves postpartum

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

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

Pustular acne

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 the touch

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage II

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

The client had a recent infestation

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

The client is consistently incontinent of urine.

The nurse is admitting a 79-year-old man for outpatient surgery. The client 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?

The client may have been abused.

A nurse implements which skin assessment to determine the presence of dehydration in a client?

Turgor

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

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

hypothyroidism.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule

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

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

sclera