Ch 14: Assessing Skin, Hair, and Nails

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 -Protects against damage to the body from sunlight -Helps make vitamin D in the body -Aids in maintaining body temperature

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

What is the rationale for asking the client whether he or she has noticed any new or changed moles?

Changes in existing moles or the appearance of new moles can indicate melanoma.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment of this client for findings associated with which disease process?

Cushing's disease

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin...

D

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

UV radiation exposure

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 is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis

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

allow early identification of neurologic deficits

To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears...

ashen

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

asymmetrical shape

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

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?

clustered

Which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility

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

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

fainting

When assessing your new patient, you note that he has no hair on his legs. What might this indicate about the patient?

he has peripheral artery disease

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

macules

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

osteomyelitis

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

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

symptoms of stress

How should the nurse palpate the skin of a client to assess its texture?

touch with the palmar surface of the three middle fingures

The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?

trichotillomania

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

use two fingers to pinch the skin under the clavicle

Short, pale, and fine hair that is present over much of the body is termed...

vellus

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

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

acne

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

carotene

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

dermis

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

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

inspect the area

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules

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

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

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

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

synthesis of vitamin D

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

the client exhibits no signs or symptoms of infection

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

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

dermis

A patient 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 patient 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

What does examination of skin involve? Select all that apply.

inspection palpation

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

distribution

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

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

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

A patient with a zosteriform rash has a rash that

is distributed along a dermatome

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

keloid formation at the site of an old incision

The nails, located on the distal phalanges of the fingers and toes, are composed of...

keratinized epidermal cells

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 patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient 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

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?

psoriasis

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

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

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

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