Chapter 55: Assessment of Integumentary Function

A client is concerned about finding a few strands of hair on a pillow after sleeping and additional strands on the brush when styling the hair. Which response will the nurse make regarding the client's concern? "There are approximately 100 strands of hair lost per day." "Losing hair means the hair follicles are dying." "That is an unusual amount and should be evaluated." "Most people who lose hair have an undiagnosed illness."

"There are approximately 100 strands of hair lost per day."

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client? Recommend the client speaks with a health care provider about currettage which is the most common treatment. Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Reassure the client that the condition usually resolves if dietary restrictions limiting caffeine and alcohol are followed. The client should consider changing careers as stress plays a significant role in this condition.

Avoidance of direct sunlight with protective clothing measures should be discussed with the client.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? Orange-green Bronze Yellow Gray

Bronze

A nurse assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement? Provide addtional blankets for this client. Check the client's oral temperature. Monitor normal variation in skin color. Lower the thermostat in the client's room.

Check the client's oral temperature.

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? Discolored Clubbing Concave Brittle

Clubbing

The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss? Convection Evaporation Conduction Radiation

Conduction

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Stratum corneum Dermis Papillary layer Epidermis

Dermis

The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based? Rash Xanthelasmas Seborrheic keratosis Eczema

Eczema

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? Greater than 1 cm in diameter Flat with skin color change Circumscribed border Elevated and palpable

Elevated and palpable

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? Sebum deficiency Protein deficiency Dehydration Fluid retention

Fluid retention

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. Endocrine glands Subcutaneous tissue Hair Skin Fingernails

Hair Skin Fingernails

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding? Hyperpigmentation Jaundice Hirsutism Alopecia

Hirsutism

Production of melanin is controlled by a hormone secreted by which gland? Adrenal Thyroid Hypothalamus Parathyroid

Hypothalamus

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? Anemia Psoriasis Local trauma Hypoxia

Hypoxia

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? Iron deficiency anemia Poor circulation Long-standing cardiopulmonary disease Fungal infection

Iron deficiency anemia

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding? It is a cherry angioma that is a normal age-related skin alteration. It is a telangiectasia that is associated with varicose veins. It is a spider angioma that is associated with liver disease. It is an ecchymosis that is associated with trauma and bleeding.

It is a cherry angioma that is a normal age-related skin alteration.

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? Cherry red face Jaundice Bronzed appearance Pallor

Jaundice

Which is the principal hardening ingredient of the hair and nails? Melanin Merkel cells Sebaceous gland Keratin

Keratin

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? Papule Plaque Macule Patch

Macule

Which of the following is the most common cause of hair loss? Radiation Chemotherapy Male pattern baldness Nutritional deficiency

Male pattern baldness

Which of the following pigments influences hair color? Melanin Pheromones Sebum Keratin

Melanin

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? Fingernails Oral mucosa Sclera Nose

Oral mucosa

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding? Sparse hair, white in color Knots in hair when brushed Dry, brittle hair Pearly white substance that is attached to the hair shaft that is not removed with brushing

Pearly white substance that is attached to the hair shaft that is not removed with brushing

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? Telangiectasias Cherry angiomas Petechiae Ecchymoses

Petechiae

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: Flat macules with irregular borders. Flat, mole-like lesions. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Palpable, solid tumors >3 cm.

Pus-filled vesicles; circumscribed and elevated masses >0.5 cm.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? Cyst Macule Pustule Vesicle

Pustule

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Ulcer Scar Crust Scale

Scale

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? Erosion Cyst Pustule Spider angioma

Spider angioma

When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water? Stratum granulosum Stratum lucidum Stratum germinativum Stratum corneum

Stratum corneum

Sudoriferous glands secrete which type of substance? Oil Sweat Cerumen Hormones

Sweat

Petechiae are associated with which of the following disorders? Acute respiratory distress syndrome (ARDS) Deep vein thrombosis Thrombocytopenia Pulmonary emboli

Thrombocytopenia

Which diagnostic test is used to examine cells from herpes zoster? Skin scrapings Tzanck smear Skin biopsy Patch testing

Tzanck smear

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? Macule Papule Wheal Vesicle

Vesicle

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? Lichenification Hirsutism Vitiligo Telangiectases

Vitiligo

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? Yellowish waxy deposits on the eyelids Bright red moles Liver spots Dark discoloration of the skin

Yellowish waxy deposits on the eyelids

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as telangiectasia. ecchymosis. petechiae. spider angioma.

petechiae

A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum? trapping debris in the external ear prevents drying and cracking of the skin and hair cooling overwarm skin contributing to acidity of perspiration to decrease microbial growth

prevents drying and cracking of the skin and hair

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as wheals. pustules. cysts. vesicles.

vesicles.