HA: Chapter 14- Skin, Hair, Nails
A client is diagnosed with a stage IV pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
pg. 272
The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as:
vitiligo
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. 272
Which technique should the nurse use to properly assess a client's skin turgor?
Pinch the skin over the clavicle and observe its return to the original shape pg. 264
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 pg.266
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. pg.275
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 pg. 260
What is the most important focus area for the integumentary system?
UV radiation exposure pg.247
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 pg. 260
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
macules. pg. 267
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. pg. 273
A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?
patchy, thin hair pg. 251
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution pg. 277
A client is diagnosed with a stage I pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
pg. 271
A client is diagnosed with a stage II pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
pg. 271
A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?
67-year-old White female pg. 249
The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?
A neuropathic ulcer can develop without feeling it.
The student nurse learns that examining the skin can do all of the following except?
Allow early identification of neurologic deficits pg. 259
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure pg. 255
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure pg. 255
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 pg. 274
The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?
Burning when having an MRI pg. 253
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis pg. 248
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. 249
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area pg. 259
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?
Osteomyelitis pg. 272
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 pg. 259
Which of the following is an important function of the skin?
Synthesis of vitamin D pg. 247
The nurse expects what change in a client's hair as a result of aging?
The amount of hair decreases. pg. 251
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. 277
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal pg. 273
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light pg. 263
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast pg. 249
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
ashen pg.260
A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?
folliculitis pg. 264
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. pg. 251
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 explains to the client that there is a genetic component with skin cancer, especially
malignant melanoma. pg. 252
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa. pg. 260
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on body sites with heavy sun exposure pg. 276
The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as
stage II. pg. 271
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. pg. 271
Connecting the skin to underlying structures is/are the
subcutaneous tissue pg. 248
While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?
"How has it changed?" pg. 250
A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?
"It takes about 6 months to totally replace a fingernail." pg. 251
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 pg.247
When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)
-Red or light hair -freckles -immunosuppression pg. 255
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle pg. 272
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 pg. 277
The nurse in a clinic is caring for a 19-year-old male client who has a new onset of vesicles around the mouth and chin. The nurse completes an assessment, reviews data collected, and is determining which condition the client is experiencing. Complete the table of possible conditions by choosing from the list of assessment findings.
Condition and Assessment finding- -Herpes simplex: Clustered, fluid-filled vesicles -Cyst: Lesion that is walled off containing fluid or semisolid material -Impetigo: Bullae that rupture and ooze serous fluid forming a honey-colored crust pg. 273-274
During an assessment the nurse performs the action shown in this image. What is the purpose of this action?
Determine capillary refill pg. 267
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 pg. 263
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?
Hypothyroidism pg. 251
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
Impetigo pg. 274
When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:
Palmar surfaces pg. 249
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 pg. 273
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 pg.266
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 pg. 273
A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown?
a 30-year-old male who sustained a spinal cord injury who is now paraplegic pg. 269
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis. pg. 248
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia. pg. 266
The only layer of the skin that undergoes cell division is the
innermost layer of the epidermis. pg. 248
Short, pale, and fine hair that is present over much of the body is termed
vellus. 249
