Ch 14 Assessing Skin, Hair, & Nails PrepU
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 Explanation: 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.
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? Assists in keeping the skin intact Assists in friction protection Assists in protection from infection Assists in keeping skin dry
Assists in friction protection Explanation: 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.
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer
Dermis Explanation: 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.
Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. eccrine glands. keratinized tissue. dermis.
dermis. Explanation: 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.
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea diaphoresis
fainting Explanation: 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.
Connecting the skin to underlying structures is/are the papillae. sebaceous glands. dermis layer. subcutaneous tissue.
subcutaneous tissue. Explanation: Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.
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? "Do you know how to check for signs of skin cancer?" "Sometimes moles change as you age." "When did you notice the change?" "How has it changed?"
"How has it changed?" Explanation: 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 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? 1 2 3 4
3 Explanation: 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.
Recommended protective measures to avoid skin cancer include which of the following? Avoiding sun exposure Knowing signs of skin cancer Performing monthly skin self-examinations Seeking biannual examination by a clinician after age 40 years
Avoiding sun exposure Explanation: 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.
The nurse should use which assessment tool to assess the client's risk for skin breakdown? Braden Scale Hendrich II Morse Scale VTE prophylaxis algorithm
Braden Scale Explanation: The Braden Scale or Norton Scale, or another skin assessment tool should be used to assess for skin breakdown risk factors according to hospital standard protocol. The Hendrich II and Morse scale assess fall risk. Upon admission, clients are evaluated for venous thromboembolism (VTE) risk; but a separate skin assessment tool is used as well.
The nurse is performing a focused assessment on a 45-year-old client of African descent. The nurse observes the following: nail beds have pigmented streaks, 160-degree angle between the nail base and the skin. What action should the nurse take? Document the findings as normal. Request a prescription for bacterial infection. Place a consult for a nutritionist to address anemia. Notify the health care provider of abnormal findings.
Document the findings as normal. Explanation: Dark-skinned clients may have freckles or pigmented streaks in their nails. There is normally a 160-degree angle between the nail base and the skin. The nurse would therefore document these findings as normal, and would not contact the health care provider. Bacterial infections cause green, black, or brown nail discoloration. Spoon nails (concave) may be present with iron deficiency anemia.
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 Ask further questions Document the statement Move on to next body system
Inspect the area Explanation: 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.
Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis
Keloid formation at the site of an old incision Explanation: 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 assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy
Psoriasis, fungal infections, trauma Explanation: 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.
The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown? Eschar on an area near a bony prominence Excessive sweating on a dependent body region Skin that feels boggy on palpation Loss of the dermis
Skin that feels boggy on palpation Explanation: Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.
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 The client has melanoma The client has COPD The client has asthma
The client has chronic hypoxia Explanation: 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 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? Multiple nevi Tinea versicolor Herpes simplex Tinea corporis
Tinea corporis Explanation: 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? Anterior chest Upper abdomen On the neck Under the breast
Under the breast Explanation: 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.
A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown? a 49-year-old female with a long history of Parkinson disease who walks with a cane a 75-year-old male with left-sided hemiparesis who is ambulatory with a quad walker a 66-year-old female who underwent hip surgery 2 days ago and is working with physical therapy a 30-year-old male who sustained a spinal cord injury who is now paraplegic
a 30-year-old male who sustained a spinal cord injury who is now paraplegic Explanation: Risk factors for skin breakdown include immobility, incontinence, lack of sensory perception, poor nutrition and hydration, and conditions that impair blood flow. A client with a spinal cord injury has decreased mobility and sensation, so this client is at highest risk for skin breakdown. Although the clients in the other options have some impairment in their mobility, they are still ambulatory.
Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.
vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.