Ch.14 Assessment

hypothyroidism

A 20 yo 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

fluid intake

A female client visits the clinic and complains to the the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate

subcutaneous tissue

Connecting the skin to underlying structures is

dermis

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

vellus

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

overall amount of sun exposure

Squamous cell carcinoma is associated with...

areola of the breast

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

keratinized epidermal cells

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

plaque

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a

a recent illness

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

hypoxia

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

caused by aging of the skin in older adults

While assessing the skin of an older adult, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

bulla

an elevated, circumscribed, fluid-filled lesion; greater than 1 cm in diameter

nevus

congenital pigmented area on the skin, for example, mole, birthmark

annular

describes a lesion that forms a ring around a clear center of normal skin

wheal

elevated, solid, transient lesion; often irregularly shaped; an edematous

induration

hardening of the skin, usually caused by edema

Urticaria

hives, pruritic wheals, often transient and allergic in origin

keloid

hypertrophic scar tissue; prevalent in nonwhite races

Papule

solid, elevated, circumscribed, superficial lesion; 1 cm or less in diameter

Lichenification

thickening of the skin characterized by accentuated skin markings

petechia

tiny, flat, purple or red spots on the surface of the skin resulting from minute hemorrhage

malignant melanoma

A client visits the clinic for a routine physical exam. The nurse prepares to assess the client's skin. The nurse asks if there is a family history of skin cancer and should explain to the client that there is a generic component with skin cancer, especially

risk for ineffective health maintenance related to deficient knowledge of effect of sunlight on skin lesions

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 exam and tells the nurse that she continues to swim in the sunlight 3 times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

volume of blood circulating in the dermis

A client's skin color depends on melanin and carotene contained in the skin, and the...

sclera

A dark-skinned patient visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's

filter for dust

A primary function of hair in the nose and eyelashes is to serve as a...

keloid

An African Am. female visits the clinic and tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a

domestic abuse

An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing

symptoms of stress

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

fissures

An adult male 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

oral mucosa

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should asses for central cyanosis by observing the client's

stage II

The nurse assesses an older adult who is bedridden in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosin. The nurse should document the client's pressure ulcer as

a great degree of cyanosis

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 should document the presence of

chronic discoid lupus erythematosus

The nurse is assessing an African Am. client's skin. After the assessment, the nurse should instruct the client that African Am. persons are more susceptible to

squamous cell carcinomas are most common on body sites with heavy sun exposure

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

vesicles

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

innermost layer of the epidermis

The only layer of the skin that undergoes cell division is the...

vitamin D

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

use two fingers to pinch the skin under the clavicle

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

ashen

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

macules

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

blue

While assessing an adult's feet for fungal disease using a Wood Light, the nurse documents the presence of a fungus when the fluorescence is