Ch 11 PrepU

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 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.

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 risk for melanoma is increased in people older than 50 years; this client is 35 years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas.

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.

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

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?" Asking an open-ended question will elicit a more complete response, such as how the mole has changed for example, diameter, color, shape). The other options will not elicit the information needed to direct next priority actions. Telling the client that moles change as we age is not an appropriate response; further assessment is needed. Asking if the client knows how to check for signs of skin cancer and about when they noticed the change are close-ended questions that will not provide the information needed.

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 Hirsutism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

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.

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 Folliculitis is an infection of the follicle causing pustules and erythema. Alopecia is thinning of the hair. Scalp ringworm is a fungal infection that is scaly, red, and itchy and may cause bald patches in children; it is also known as tinea capitis.

Connecting the skin to underlying structures is/are the

subcutaneous tissue.

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."

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

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.

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

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

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

Do you take steroid medications on a regular basis?" Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

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. Hair loss is a normal finding when a client is receiving chemotherapy. There is no need to notify the health care provider or for the client to stop chemotherapy. Even though the nurse may educate the client on alopecia and the use of hair wraps, wigs, or shaving of the head, this is not the best answer.

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?

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.

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

Expose only the body part that is being examined When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

The nurse is preparing to examine a client's skin. What would the nurse do next?

Expose only the body part that is being examined. When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

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." Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

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 takes about 6 months to totally replace a fingernail." It takes 6 months to totally replace a fingernail and 12 months to totally replace a toenail. A week is too short for nail regrowth. Telling the client that the nail will never be the same is not providing accurate information or therapeutic communication.

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

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

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, non-palpable 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 it 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 is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

Monthly Coupled with a yearly skin examination by a doctor, a client should examine his or her skin every month to detect early warning signs of the three main types of skin cancer.

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 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.

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.Q

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 This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

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 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.

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

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

Stratum corneum The epidermis consists of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum, in that order.

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.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

There is a non-blanching reddened area on the client's coccyx region. Non-blanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

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

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 nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness. Beau's lines occur after acute illness and eventually grow out.

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

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 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 The thyroid gland controls metabolism. In hypothyroidism, the slowed metabolism decreases the rate of hair growth, resulting in thin patchy hair. This is more pronounced than typical age-related changes in hair. Hypothyroidism does not cause premature graying of hair. Increased facial hair is seen in Cushing's disease as a result of increased sex hormones from the adrenal gland (hirsutism).

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

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

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.

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 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.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

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.

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 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.