(PrepU) Chapter 14: Assessing Skin, Hair, and Nails

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

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

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.

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 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.

The student nurse learns that examining the skin can do all of the following except?

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.

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?

Call for help and use the draw sheet to move the client. Friction and shear forces are risk factors for developing pressure ulcers. The nurse should ask for help and use a draw sheet to avoid shearing forces. Pulling the client up in bed and allowing the client to slide in bed create friction and shear forces. Pushing the client also creates shearing forces.

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.

Which of the following terms is used to describe the arrangement of skin lesions?

Annular Annular, or arciform, lesions are typical of the pattern and arrangement associated with tinea faciale. The terms exposed, localized, and generalized are not commonly used to describe the arrangement of lesions.

Which of the following statements most accurately conveys an aspect of the anatomy and physiology of the skin?

The skin is composed of an epidermis, dermis, and subcutaneous tissue. The skin is commonly divided into the three layers of the epidermis, dermis, and subcutaneous tissue. Migration to the epidermis takes approximately 1 month, and vitamin D synthesis is a function of the skin. Color is primarily a result of pigmentation.

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

Palmar surfaces The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.

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?

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.

To assess an adult client's skin turgor, the nurse should

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

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 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.

Why is it important for the nurse to ask the client what they think caused a skin condition?

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.

A nursing instructor is teaching nursing students about hair. Which of the following statements represents the students' understanding of hair? Select all that apply.

"There are two types of hair: vellus and terminal." "Hair grows on most of the body except some areas such as lips." "Nasal hair filters dust and other airborne debris." There are different types of hair: vellus, which is like peach fuzz, found on most of the body; and terminal hair, which is found on the scalp and eyebrows. Gray or white hair is caused by a reduction in production (not total loss) of pigment. Vellus hair, not terminal hair, provides thermoregulation by wicking sweat away from the body. Nasal hair filters dust and other airborne debris.

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?" Excessive nail biting may be a sign of anxiety. Although anxiety and depression can occur at the same time, nail biting is a sign of anxiety. While the nurse may want to find out if the nail biting is new, and while nail biting may run in the family, these are not the priority in this situation.

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 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?

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

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 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.

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

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.

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

fainting Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

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. 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.