PrepU ch.14 assessing skin, hair, and nails

The apocrine glands are stimulated by what? a.Emotional stress b.Temperature c.Physical stress d.Overhydration

a. Emotional stress The eccrine glands are widely distributed, open directly onto the skin surface, and by their sweat production help to control body temperature. In contrast, the apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress.

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

d. dermis. The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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

a. vellus. Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears... agreenish. bashen. c.bluish. d.olive.

b. ashen Pallor (loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.

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? a.1 b.2 c.3 d.4

c. 3 A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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

d. use two fingers to pinch the skin under the clavicle. To assess turgor, gently pinch the skin over the clavicle with two fingers.

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply. -Evaluate the client's outcomes -Modify nursing interventions -Keep to the established care plan -Document the findings -Notify the physician

-Evaluate the client's outcomes -Modify nursing interventions The nurse evaluates care according to the developed client outcomes, thereby reassessing the client and continuing or modifying the interventions as appropriate. The care plan is a guide, something that changes with the client's status. There is no need to notify the physician. Documenting findings needs to be done, but it does not improve the client's outcome.

When inspecting the hair, what would the nurse note? (Select all that apply.) Color Condition of hair shaft Length of hair Hair breakage of more than 6 hairs Hair shafts that are shiny

Color Condition of hair shaft Hair shafts that are shiny During hair inspection, the nurse notes color, consistency, distribution, areas of hair loss, and condition of the hair shaft. Length of hair and hair breakage of more than 6 hairs are not things the nurse typically inspects.

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: a.symptoms of stress. b.recent radiation therapy. c.pigmentation irregularities. d.allergies to certain foods.

a. symptoms of stress. Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what? (Select all that apply.) Lymphatic vessels Connective tissue Vernix Blood vessels Sweat glands

Lymphatic vessels Blood vessels Sweat glands The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects the infant's skin. Connective tissue is found in the subcutaneous layer of the skin.

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? a.Assists in keeping the skin intact b.Assists in friction protection c.Assists in protection from infection d.Assists in keeping skin dry

b. Assists in friction protection Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

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

a. Avoiding sun exposure While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

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? a.Iron deficiency anemia b.Cushing's disease c.Basal cell carcinoma d.Lupus erythematosus

b. Cushing's disease Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

The nurse is admitting a 79-year-old man for outpatient surgery. The client 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? a.The client may have been abused. b.The client is elderly. c.The client may have peripheral vascular disease. d.The client may have a cognitive deficit.

a. The client may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

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

b. caused by aging of the skin in older adults. Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

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? a.Around the mouth and lips b.Chest and abdomen c.Fingers and toes d.Nose and earlobes

c. 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.

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? a.Unbroken but red in color b.Ulceration resembling a crater c.Exposure of subcutaneous tissue and muscle d.Broken with the presence of a blister

d. Broken with the presence of a blister A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.

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

a. Synthesis of vitamin D A vital role of the skin is the synthesis of vitamin D. Carotene exists in sebaceous fat, and melanin deposits are a normal component of skin. Skin does not significantly contribute to pH maintenance.

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? a.1 b.2 c.3 d.4

c. 3 A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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? a.Moist and smooth b.Moist and rough c.Dry and smooth d.Dry and rough

d. Dry and rough A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

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

-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 skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in the digestion of food.

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply. -the loss of skin turgor as a result of aging -a cancerous skin lesion located on the back -presence of a systemic disease like measles -a rash triggered by taking the medication ibuprofen -a reddened area on the heel that indicates a potential risk for pressure ulcer formation

-a cancerous skin lesion located on the back -presence of a systemic disease like measles -a rash triggered by taking the medication ibuprofen -a reddened area on the heel that indicates a potential risk for pressure ulcer formation For the nurse, assessment of the skin is much more than discovering skin lesions or diseases. Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration, overhydration, or physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation. The loss of skin turgor attributed to aging is not considered a medical outcome or disease.

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? a.The client has chronic hypoxia b.The client has melanoma c.The client has COPD d.The client has asthma

a, The client has chronic hypoxia Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

What is the rationale for asking the client whether he or she has noticed any new or changed moles? a.Changes in existing moles or the appearance of new moles can indicate melanoma. b.Transition from pustules to moles can indicate psoriasis c.The appearance of new moles is a sign of vitamin D deficiency. d.Excessive eccrine sweat gland production can cause the emergence of a new mole.

a. Changes in existing moles or the appearance of new moles can indicate melanoma. Assessment of moles, both by client and clinician, is important in the early detection of melanomas. Moles are not a relevant finding in cases of psoriasis, vitamin D deficiency, and excess sweat production.

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

a. Dermis The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? a.Impetigo b.Psoriasis c.Herpes zoster d.Viral Exanthem

a. Impetigo Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthem is a macular or papular rash that is present along with a viral infection.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? a.Inspect the area b.Ask further questions c.Document the statement d.Move on to next body system

a. Inspect the area If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

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? a.Nodule b.Papule c.Vesicle d.Macule

a. Macule A macule is a flat, nonpalpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule. A circumscribed elevated mass containing fluid is called a vesicle or bulla, depending on its size. A nodule is a solid, palpable mass. A papule is an elevated, palpable, solid mass that is smaller in diameter than a nodule.

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

a. Psoriasis, fungal infections, trauma Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

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

a. The client's perception affects the approach and effectiveness in treating the skin condition The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies.

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

a. UV radiation exposure 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. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

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

a. areola of the breast. The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

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... a.hypothyroidism. b.hyperthyroidism. c.infectious conditions. d.hypoparathyroidism.

a. hypothyroidism. Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of... a.macules. b.papules. c.plaques. d.bulla.

a. macules Freckles are flat, small macules of pigment that appear following sun exposure.

Squamous cell carcinoma is associated with... a.overall amount of sun exposure. b.intermittent exposure to ultraviolet rays. c.precursor lesions. d.an increase in the rates of melanoma.

a. overall amount of sun exposure. Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

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

b. Allow early identification of neurologic deficits Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

A client 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 client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn? a.The damage to keratin producing cells in the epidermis layer b.Destruction of hair follicles located in the dermis layer c.The impairment of apocrine gland to function effectively in the subcutaneous layer d.The ability of the adipose layer to produce carotene has been destroyed

b. Destruction of hair follicles located in the dermis layer Damage to hair follicles located in the dermis layer of the skin would result in the body's inability to regrow hair on burn damaged areas. The remaining options suggest correct information but none are associated with the regrowth of hair after a burn.

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? a.Onset of iron deficiency anemia b.History of cigarette smoking c.Environmental exposure to chemicals d.Treatment for fungal infections in the past

b. History of cigarette smoking Explanation: An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Assessing Skin, Hair, and Nails, p. 264. Chapter 14: Assessing Skin, Hair, and Nails - Page 264

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? a.Diabetes mellitus b.Hypothyroidism c.Crohns disease d.Cushing disease

b. Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Cushing disease can result in female facial hair growth.

A client's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the client's risk for pressure sore development is: a.No risk b.Mild risk c.Moderate risk d.High risk

b. Mild risk The Braden Scale assesses six factors for the development of pressure sores: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The higher the score, the lower the risk. A score of 19 to 23 would be no risk. A score of 15 to 18 would be mild risk. The client's score is 16, which is a mild risk. A score of 13 to 14 is moderate risk. A score of 10 to 12 is a high risk.

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely? a.Actinic keratosis b.Seborrheic keratosis c.Basal cell carcinoma d.Squamous cell carcinoma

b. Seborrheic keratosis Explanation: This is a typical description for seborrheic keratosis. The stuck on appearance and rough wart-like texture are key features. These lesions often produce greasy scales when scratched with a fingernail, which further helps to distinguish them. Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish them to prevent unnecessary biopsy; however, it is important to consider biopsy whenever there is any doubt. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Assessing Skin, Hair, and Nails, p. 266. Chapter 14: Assessing Skin, Hair, and Nails - Page 266

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client? a.Skin self-examination b.Signs and symptoms of melanoma c.Recognizing different types of lesions d.Protection from sun damage

b. Signs and symptoms of melanoma A simple method is to use the ABCDEs of melanoma detection: Asymmetry, Border irregularity, Color, Diameter of more than 6 mm, Evolution of lesion over time. The other given options are correct, but the most appropriate response is teaching about melanoma.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? a.Clubbing b.Spooning c.Beau's lines d.Paronychia

b. Spooning Explanation: Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Assessing Skin, Hair, and Nails, p. 264. Chapter 14: Assessing Skin, Hair, and Nails - Page 264

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... a.stage I. b.stage II. c.stage III. d.stage IV.

b. stage II. Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

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? a.Stratum corneum b.Stratum lucidum c.Dermis d.Epidermis

c. Dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

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? a.Allow the client to pray before the examination b.Let the client remained fully dressed for the examination c.Have a nurse who is the same sex as the client examine him d.Avoid asking any questions regarding the client's lifestyle

c. Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

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

c. Skin warm and dry to the touch Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? a.Sunlight b.Artificial light c.Wood's light d.Flashlight

c. 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 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... a.nodules. b.bullae. c.vesicles. d.wheals.

c. vesicles Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

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... a.nodules. b.bullae. c.vesicles. d.wheals.

c. vesicles. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

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

d. Document the findings in the client's record as normal Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating.

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? a.Reynaud disease b.Central cyanosis c.Neurofibromatosis d.Peripheral cyanosis

d. Peripheral cyanosis Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

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? a.Seborrhea b.Contact dermatitis c.Eczema d.Psoriasis

d. Psoriasis Psoriasis is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

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? a.Transverse white lines in the nails b.Beau's lines c.White spots, or leukonychia, on the nail surfaces d.Small pits in the surfaces of the nails

d. Small pits in the surfaces of the nails Explanation: Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Assessing Skin, Hair, and Nails, p. 264. Chapter 14: Assessing Skin, Hair, and Nails - Page 264

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? a.Multiple nevi b.Tinea versicolor c.Herpes simplex d.Tinea corporis

d. Tinea corporis 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. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

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? a.Anterior chest b.Upper abdomen c.On the neck d.Under the breast

d. Under the breast The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

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? a.Moist and smooth. b.Moist and rough c.Dry and smooth d.Dry and rough

d. dry and rough A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

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... a.basal cell carcinoma. b.actinic keratoses. c.squamous cell carcinoma. d.malignant melanoma.

d. malignant melanoma. Explanation: Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Assessing Skin, Hair, and Nails, p. 251. Chapter 14: Assessing Skin, Hair, and Nails - Page 251

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

d. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

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

d. underarms The apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress. This type of gland does not secret on locations identified by the other options.

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 Hemochromatosis Normal aging

Fungal infections Trauma Warts Onycholysis is separation of a portion of the nail plate from the nail bed, resulting in an opaqueness to the affected part of the nail, appearing white, yellow, or green. Causes include trauma, fungal infections, topical irritants, psoriasis, subungual neoplasms, and warts. Normal aging is not a cause of this condition. Hemochromatosis is a hereditary disorder affecting iron metabolism.

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

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

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? a.Type b.Color c.Distribution d.Arrangement

c. Distribution The given terms denote anatomic location, or distribution, of skin lesions over the body.

The nails, located on the distal phalanges of the fingers and toes, are composed of... a.ectodermal cells. b.endodermal cells. c.keratinized epidermal cells. d.stratum cells.

c. keratinized epidermal cells. The nails, located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the cuticle.

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.heart sounds b.bowel sounds c.pulse oximetry d.body temperature

c. pulse oximetry 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.

Connecting the skin to underlying structures is/are the... a.papillae. b.sebaceous glands. c.dermis layer. d.subcutaneous tissue.

d. subcutaneous tissue. Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.