NURS 212 -- Chapter 14 PrepU Review

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

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 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.

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.

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.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

i. intact, firm skin with redness ii. ulceration involving the dermis iii. full-thickness skin loss iv. necrosis with damage to underlying muscle

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

Dermis

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

Distribution

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.

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 is admitting a 79-year-old man for outpatient surgery. The patient 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 patient may have been abused.

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

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

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

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.

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

the reduction of red pigment in the arteries

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarms

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

use two fingers to pinch the skin under the clavicle.

Short, pale, and fine hair that is present over much of the body is termed

vellus.

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 RN should intervene and further educate the nursing assistant when observing which action?

Independently pulling an immobile client up in bed

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

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

Keloid formation at the site of an old incision

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

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

dermis.

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene

Local redness of the skin warns of impending necrosis.

True

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.

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 apocrine glands are stimulated by what?

Emotional stress

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

Acne

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

Osteomyelitis

When educating a patient about the risks of malignant melanoma, what would you know to include? (Mark all that apply.)

-Red or light hair -Freckles -Immunosuppression

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 cm -asymmetry

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 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

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client?

Age

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

Allow early identification of neurologic deficits

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

Avoiding sun exposure

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

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

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

Cushing's disease

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

Decreased skin mobility

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

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 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

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?

Skin tags are common benign skin lesions

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

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

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

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

Touch with the palmar surface of the three middle fingers.

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

UV radiation exposure

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.

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo

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

Wheal

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

Wood's light

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue.

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

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 documenting that a patient has freckles, the appropriate term to use is

macules

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 should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma.

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 mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies

A patient has sustained burns over 50% of the body. When planning care for this patient, 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

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

15

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

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

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

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

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

ashen.

Squamous cell carcinoma is associated with

overall amount of sun exposure.

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.