Quiz 3

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

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

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

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

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

UV radiation exposure

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis

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

fainting

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 client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

inspect the area

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

malignant melanoma

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

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 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

Connecting the skin to underlying structures is/are the

subcutaneous tissue

Which of the following is an important function of the skin?

synthesis of vitamin d

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries

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

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

vesicle

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?

3

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

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

Wood's light

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

acne

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

allow early identification of neurologic deficits

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

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

carotene

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?

cushing's disease

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 nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

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?

destruction of hair follicles located in the dermis layer

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 apocrine glands are stimulated by what?

emotional stress

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

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

hypoxia

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 full-thickness skin loss necrosis with damage to underlying muscle

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

keloid formation at the site of an old incision

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

macules

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

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

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

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures

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

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

vesicles