Prep U Assessing Skin, Hair, and Nails

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?

"Do you feel anxious at times?"

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?

"How has it changed?"

A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse? -"I understand your concern, but this is a normal part of aging." -"It sounds like you have developed peripheral neuropathy." -"It sounds like you may have developed a deep vein thrombosis." -"Have you ever told your health care provider this?"

"It sounds like you have developed peripheral neuropathy."

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse? - "It will only take about a week for it to fully regrow." - "It will probably take about 12 months to totally replace a fingernail." - "It takes about 6 months to totally replace a fingernail." - "It will grow back in time, but may never be the same."

"It takes about 6 months to totally replace a fingernail."

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

"My feet hurt and are always cold to the touch"

The nurse preparing to conduct an integumentary assessment will include which intervention(s) when preparing the client for this examination? Select all that apply. -Using cotton balls to assess for sensation -Using the mnemonic OLDCART as a guide -Ensuring the environment has adequate lighting -Providing adequate drapes -Assisting the client to put on a gown

-Assisting the client to put on a gown -Providing adequate drapes -Ensuring the environment has adequate lighting

A client with a family history of melanoma wants to have specific body moles assessed. In order to perform this assessment effectively, the nurse should have access to what equipment? Select all that apply. -Magnifying glass -Gloves -Warm water -Ruler -Natural lighting

-Magnifying glass -Gloves -Ruler -Natural lighting

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply. -friction created by dragging the skin against bedlinen -restlessly changing position frequently -pressure that impairs capillary blood flow to the skin -moisture being allowed to accumulate on the skin -shearing that occurs when sliding down in bed

-friction created by dragging the skin against bedlinen -pressure that impairs capillary blood flow to the skin -moisture being allowed to accumulate on the skin -shearing that occurs when sliding down in bed

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.) Age 55 years Light-colored hair Actinic keratosis on face Poor skin turgor Yellow palms of the hands

Age 55 years Light-colored hair Actinic keratosis on face

A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings?

Ask the client if they experience periods of excessive sweating

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

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

Burning when having an MRI

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

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? -Diabetes mellitus -Cushing disease -Crohn's disease -Hypothyroidism

Hypothyroidism

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic? -Erythema -Increased thickness and hair loss -Pallor -Increased thinness

Increased thinness

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

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

Palmar surfaces

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

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric

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

Pustular acne

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

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.

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

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

areola of the breast

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

ashen

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions? -fungal infection -psoriasis -hypoxia -iron deficiency anemia

hypoxia

The nails, located on the distal phalanges of the fingers and toes, are composed of

keratinized epidermal cells

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

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?

patchy, thin hair

Connecting the skin to underlying structures is/are the

subcutaneous tissue

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

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

A nurse performs a focused assessment on a client who has noticed changes in their nail beds. The nurse observes white color and separation of the nail plate from the nail bed. The nurse determines that these signs and symptoms indicate which of the following conditions?

yeast infection

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

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

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

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

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 45-year-old female with 10 year history of cigarette smoking 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years

55-year-old male who lived in California for 20 years

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

A neuropathic ulcer can develop without feeling it.

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

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

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

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

Carotene

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

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

Distribution

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take? -Document findings. -Notify the health care provider. -Inform the client to stop chemotherapy. -Suggest the client shave their head.

Document findings.

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

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking

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

Keloid formation at the site of an old incision

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

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 -Dermal -Full thickness -Superficial-dermal

Superficial

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

folliculitis

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.

The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as

stage II.