prep U#11: hair, skin, nails

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life.

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

Are you allergic to foods, medications, or other substances?

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

Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma

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?

Generalized hair loss can be a finding in hypothyroidism.

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?

In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.

freckle

Macules are skin discolorations that are flat, circumscribed, discolored, and less than 1 cm in diameter. An example of a macule is a freckle.

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

Melasma, increased pigmentation of the face in response to the hormonal changes of pregnancy, occurs mainly on the chin, cheeks, and upper lip and generally resolves postpartum but can be permanent.

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

papule

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?

A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process?

DM The appearance of a rough and dark skin around the neck area, especially in African Americans, can be an indication of diabetes mellitus. This condition is called acanthosis nigricans.

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

Iron deficiency anemia

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

dermis

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

document as normal finding *more melanin

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

A patient asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this patient'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."

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?

Assess the client for changes in sensation due to vascular problems Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor.

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?

Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists, it may indicate systemic hypoxemia.

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 2

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

faint Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency

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..Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis