Physical assessment unit 3

serpiginous

(of a skin lesion or ulcerated region) having a wavy margin.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D.

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

newborns skin is thin, smooth, and elastic, and is relatively more premeable than that of the adult, which makes puts them at a greater risk for what?

Fluid loss

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

Hypothyroidism

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse?

Renal failure

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 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

what is the major function of the skin?

To keep the body in homeostasis

melanin

brown pigment- it is responsible for various colors and tones of skin

vernix caseosa

cheesy substance

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

diameter great than 6 cm notched border asymmetry

Variables that influence skin color include

emotional stress temperature cigarette smoking prolonged elevation/dependent position of extremities prolonged inactivity

Lanugo

fine downy hair of newborn infant

sebum

holding water in the skin producing milia

carotene

is the golden yellow pigment that exist in subcutaneous fat and in heavily keratinized areas such as the palms and soles

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

macules

what are the three sources skin color is derived from?

melanin, carotene, and vascular beds

vascular bed

red-purple tones

Carotene

Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

What is considered appendages of the skin?

Hair, nails, and sebaceous and sweat glands (eccrine, apocrine glands )

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

Skin conditions that are noted to be specific to Black patients

Keloids pigmentary disorders pseudofolliclitis melasma

with aging, what is loss ?

loss of elastic, collagen, and subcutaneous fat, reduction of muscle tone

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

Wood's light- The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

The major factors that put an aging adult at risk for skin breakdown?

thinning of the skin decrease in vascularity and nutrients loss of protective cushioning of the subcutaneous layer lifetime of environmental trauma to the skin social changes of aging increasingly sedentary lifestyle chance of immobility