Health Assessment Unit 2

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurological deficits

Which of the following terms is used to describe the arrangement of skin lesions?

Annular

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 a presence of a blister

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

Dermis

A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the patient questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

Destruction of hair follicles located in the dermis layer

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

Distribution

A 64 y/o women is admitted to the hospital. She is very embarrassed about large varicose veins in the calf and thigh of both legs. The patient does not want the nurse to look at her legs. The most appropriate nursing diagnosis would be

Disturbed Body Image related to edema, legs ulcerations, or varicosities as evidence by embarrassment.

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

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

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

Macules

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?

Stage 3

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

Under the breast

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

Wood's light pg260

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

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

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

Acne

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

Areola of the breast

While assessing the peripheral vascular system of an adult patient, the nurse detects cold clammy skin and loss of hair on the patient's legs. The nurse suspects that the patient may have

Arterial insufficiency

After palpating the radial pulse of an adult patient, the nurse suspects arterial insufficiency. The nurse should next assess the patient's

Brachial pulse

A nurse observes the presence of hirsutism (facial hair on females) on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

Fainting

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

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

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 and hives

The nurse is assessing the dosalis pedis pulse on a patient using her fingertips. The nurse is not able to feel the pulse. What device would the nurse use to determine if there is blood flow at the dorsales pedis pulse?

Use a doppler ultrasound

A patient visits the clinical and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the patient for

lymphedema

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.)

pg 248 Lymphatic vessels Blood vessels Sweat glands

During a physical examination, the nurse detects warm skin and brown pigmentation around a patient's ankles. The nurses suspects that the patient may have

venous insufficiency

During an assessment, a patient says "I know that arteries and veins are blood vessels, but what is the difference?" Which of the following would the nurse include in the response?

Arteries carry oxygen rich blood. Veins carry deoxygenated, waste laden blood.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears

Ashen

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

Caused by aging of the skin in older adults

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 receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

When assessing a client's terminal hair(Scalp, eyebrows, after puberty axillae, perineum, and legs) distribution, the nurse inspects all the following areas except:

Palmar surfaces

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

Which of the following is an important function of the skin?

Synthesis of Vitamin D

The nurse is preparing to palpate the epitrochlear lymph nodes of an adult patient. The nurse should instruct the patient to

flex her elbow about 90 degrees.

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

If edema is noted during inspection, palpate the area to determine if is is pitting or nonpitting. Press the edematous area with the tip of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented what type of edema is present?

pitting

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate?

On the inside of the ankle just below the medial malleolus

The only layer of the skin that undergoes cell division is the

pg 248 innermost layer of the epidermis

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 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

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures