Health Assessment Chapter 14 Practice Questions

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

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

Which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility

Squamous cell carcinoma is associated with

overall amount of sun exposure

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

Keloid formation at the site of an old incision

A client, with a family history of melanoma, wants to have specific body moles assessed. In order to perform this assessment effectively, the nurse should have access to what equipment? (Select all that apply.)

- Examination table - Chair - Natural lighting

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.

- Moisture - Activity - Nutrition

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

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?

Reassure the mother that this is normal.

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

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.

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.

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

vesicle

A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply.

- Disturbed Body Image - Ineffective Individual Coping - Anxiety

A nurse notices that a client's nails on the right hand have separated from the nail bed and appear yellow. What could be a cause of this condition? Select all that apply.

- Fungal infections - Trauma - Warts

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 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 pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm (Pinch a fold of skin on the client's abdomen)

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

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial

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 client with a zosteriform rash has a rash that

is distributed along a dermatome

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

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as

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The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

Consider admitting the client to the hospital.

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 community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

Fluid-filled lesions less than 1 cm in diameter

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

An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?

Risk for Impaired Skin Integrity

The nurse expects what change in a client's hair as a result of aging?

Sebaceous glands will secrete less causing hair to be drier.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

Local redness of the skin warns of impending necrosis.

True

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

Wheal

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

Connecting the skin to underlying structures is/are the

subcutaneous tissue

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

use two fingers to pinch the skin under the clavicle.