HA - Ch. 11 Skin, Hair, Nails Assessment

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?

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

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?"

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 client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3 pg. 258

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

Acne

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

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

Alopecia areata pg. 290

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 "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

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

Avoiding sun exposure

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

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

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

Distribution

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 pg. 265

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

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

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

Keloid formation at the site of an old incision

A client has sustained burns over 50% of the body. When planning care for this client, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.)

Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes pg. 263

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

Osteomyelitis

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral cyanosis

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?

Petechiae

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

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric

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

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum

A client is scheduled for an MRI of the left knee. What assessment finding could cause the client to experience discomfort while having the diagnostic test?

Tattoo on the left lower leg pg. 246

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?

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?

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

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

What role does oxyhemoglobin play in the physiological process that results in pallor?

The reduction of red pigment in the arteries

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.

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?

Thin pg. 270

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 pg. 280

What is the most important focus area for the integumentary system?

UV radiation exposure

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

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

Wood's light

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis.

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.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

notched border diameter great than 6 mm asymmetry

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.

presence of a systemic disease like measles a rash triggered by taking the medication ibuprofen a reddened area on the heel that indicates a potential risk for pressure ulcer formation a cancerous skin lesion located on the back

To assess an adult client's skin turgor, the nurse should

use two fingers to pinch the skin under the clavicle.