NURS 301 Exam 2

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

Carotene

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

Acne

The student nurse learns that examining the skin can do all of the following except? Allow early identification of neurologic deficits Identify physical abuse Allow early identification of potentially cancerous lesions Reveal overhydration

Allow early identification of neurologic deficits

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin A. B12. C. D.

D

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

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? The ability of the adipose layer to produce carotene has been destroyed Destruction of hair follicles located in the dermis layer The damage to keratin producing cells in the epidermis layer The impairment of apocrine gland to function effectively in the subcutaneous layer

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? Colour Distribution Type Arrangement

Distribution

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? Suggest that the client use antiperspirant products Assess the client for changes in sensation due to vascular problems Monitor the client for additional findings of cystic fibrosis Document the findings in the client's record as normal

Document the findings in the client's record as normal

When educating a patient about the risks of malignant melanoma, what would you know to include? (Mark all that apply.) Immunosuppression Age older than 60 Red or light hair Freckles Female gender

Immunosuppression, Red or light hair, Freckles

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. Ineffective Individual Coping Risk for Infection Disturbed Body Image Anxiety Impaired Skin Integrity

Ineffective Individual Coping Disturbed Body Image Anxiety

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 Document the statement Move on to next body system Ask further questions

Inspect the area

Which of the following assessment findings most likely constitutes a secondary skin lesion? Facial lesions associated with herpes simplex Keloid formation at the site of an old incision Psoriasis Facial acne

Keloid formation at the site of an old incision

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Eyebrows Vertex Palmar surfaces Limbs

Palmar surfaces

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? Tinea infection Pityriasis rosea Eczema Psoriasis

Psoriasis

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? Contact dermatitis Psoriasis Seborrhea Eczema

Psoriasis

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Alopecia, dermatitis, chemotherapy Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Psoriasis, fungal infections, trauma

Psoriasis, fungal infections, trauma

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 Skin tags can turn into skin cancer if they are not removed Skin tags are an early precursor to more serious skin cancer conditions Skin tags need to be removed as soon as possible or they will keep growing

Skin tags are common benign skin lesions

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? Dermal Superficial Full thickness Superficial-dermal

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 asthma The client has chronic hypoxia The client has melanoma The client has COPD

The client has chronic hypoxia

A nurse implements which skin assessment to determine the presence of dehydration in a client? Temperature Thickness Texture Turgor

Turgor

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation 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? Wheal Vesicle Papule Cyst

Vesicle

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 mild degree of cyanosis. a great degree of cyanosis. hyperthyroidism. lupus erythematosus.

a great degree of cyanosis.

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the adipose tissue. entire skin surface. soles of the feet. areola of the breast.

areola of the breast.

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. carbohydrates. vitamin D. calcium.

fluid intake.

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? mild high negligible moderate

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. hyperthyroidism. hypoparathyroidism. infectious conditions.

hypothyroidism

When documenting that a patient has freckles, the appropriate term to use is vesicles macules patches bullae

macules

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 ineffective individual coping related to changes in appearance. dry flaking skin and dull dry hair as a result of disease. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. anxiety related to loss of outdoor activities and altered skin appearance.

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

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 III. stage I. stage II. stage IV.

stage II.

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 recent radiation therapy. symptoms of stress. pigmentation irregularities. allergies to certain foods

symptoms of stress.

Short, pale, and fine hair that is present over much of the body is termed terminal. lanugo. dermal. vellus.

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. nodules. bullae. wheals.

vesicles

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. 1 necrosis with damage to underlying muscle 2 intact, firm skin with redness 3 ulceration involving the dermis 4 full-thickness skin loss

2 intact, firm skin with redness 3 ulceration involving the dermis 4 full-thickness skin loss 1 necrosis with damage to underlying muscle

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? 1 3 2 4

3

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. Aids in maintaining body temperature Largest organ of the body Circulates blood throughout the body Helps make vitamin D in the body Protects against damage to the body from sunlight Involved in digestion of food

Aids in maintaining body temperature Largest organ of the body Helps make vitamin D in the body Protects against damage to the body from sunlight

Recommended protective measures to avoid skin cancer include which of the following? Knowing signs of skin cancer Performing monthly skin self-examinations Avoiding sun exposure Seeking biannual examination by a clinician after age 40 years

Avoiding sun exposure

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. purple. red. yellow.

Blue

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? Head-to-toe assessment Newton scale Norton scale Braden scale

Braden scale

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? Lower the head of bed and pull the client up with both arms. Place the client in trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client. Push the client toward the head of the bed to prevent back injury.

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

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? Lupus erythematosus Cushing's disease Basal cell carcinoma Iron deficiency anemia

Cushing's Disease

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 Imbalanced Body Temperature Altered Tissue Perfusion Disturbed Body Image Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity

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? Small lesion left forearm for one month Skin warm and dry to the touch Denies any skin color changes Dry and flaky skin in the winter months

Skin warm and dry to the touch

Which of the following is an important function of the skin? Maintenance of acid-base balance Production of carotene Synthesis of vitamin D Protection against melanin deposits

Synthesis of vitamin D

Why is it important for the nurse to ask the client what they think caused a skin condition? Doing so allows the client to decide what treatment is the best course of action The client's perception affects the approach and effectiveness in treating the skin condition Doing so encourages the client to use home remedies to reduce medical cost The nurse can alleviate the client's fears about what caused the skin condition

The client's perception affects the approach and effectiveness in treating the skin condition

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood. The client is demonstrating central cyanosis. The client's arterial blood will appear bluish when observed in the test tube. The cyanosis may be a result of a prolonged period of exposure to the cold.

The cyanosis may be a result of a prolonged period of exposure to the cold.

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 a cognitive deficit. The patient is elderly. The patient may have been abused. The patient may have peripheral vascular disease.

The patient may have been abused.

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 signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

caused by aging of the skin in older adults.

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 signs of dermatitis. precancerous lesions. signs of an infectious process. caused by aging of the skin in older adults.

caused by aging of the skin in older adults.

Hair follicles, sebaceous glands, and sweat glands originate from the eccrine glands. keratinized tissue. epidermis. dermis.

dermis

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. ulcers. erosion. scales.

fissures

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? heart sounds bowel sounds body temperature pulse oximetry

pulse oximetry

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body? face palms of the hands underarms soles of the feet

underarms

To assess an adult client's skin turgor, the nurse should use the fingerpads to palpate the skin at the sternum. use two fingers to pinch the skin under the clavicle. press down on the skin of the feet. use the dorsal surfaces of the hands on the client's arms.

use two fingers to pinch the skin under the clavicle.