Jensen 11

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

"These are considered a normal age-related change in the skin."

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 "ABCDE" characteristic of malignant melanoma?

Asymmetrical shape

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

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

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

pulse oximetry

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

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

Allow early identification of neurologic deficits

A client 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 client 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

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?

Discrete

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

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

Expose only the body part that is being examined

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

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

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

Hirsutism

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

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

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

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

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.

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.

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

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

areola of the breast

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.

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate

fluid intake.

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.

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.

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?

Circulatory

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage II

When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition?

Sun exposure

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 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."

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?

It is likely to be related to her lupus.

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

Hair follicles, sebaceous glands, and sweat glands originate from the

dermis.