Chapter 14: Assessing Skin, Hair, and Nails
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed? stage 4
Osteomyelitis This is a diagram of a stage IV pressure ulcer. Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible. (bone infection)
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
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for
symptoms of stress. Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.
What data collected during an integumentary assessment should cause the nurse to be concerned that a patient is at risk for the development of skin cancer?
Age 55 years Light-colored hair Actinic keratosis on face
The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?
Assists in friction protection Sebum, an oil-like substance, assists the skin in moisture retention and friction protection
During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
Existence of systemic diseases that have skin manifestations
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 burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.)
Lymphatic vessels Blood vessels Sweat glands 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.
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Psoriasis
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
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?
ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.
What is the rationale for asking the client whether he or she has noticed any new or changed moles
Changes in existing moles or the appearance of new moles can indicate melanoma.
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 Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion. Primary lesions include the macule, papule, patch, plaque, vesicle, bulla, nodule, tumor, wheal, and pustule. Secondary lesions are a modification of primary lesions
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 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.
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. Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.
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.
The student nurse learns that examining the skin can do all of the following except?
skin does not Allow early identification of neurologic deficits Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.
