Chapter 14: Assessing Skin Hair and Nails

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin D. B12. C. A.

D

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Eczema, melanoma, herpes zoster Vitiligo, hirsutism, vitamin deficiency Psoriasis, fungal infections, trauma Alopecia, dermatitis, chemotherapy

Psoriasis, fungal infections, trauma

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client? Skin self-examination Signs and symptoms of melanoma Recognizing different types of lesions Protection from sun damage

Signs and symptoms of melanoma

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

carotene

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are precancerous lesions. signs of dermatitis. caused by aging of the skin in older adults. signs of an infectious process.

caused by aging of the skin in older adults

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? Epidermis Dermis Stratum corneum Stratum lucidum

dermis

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

distribution

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? Papule Nodule Vesicle Macule

macule

While assessing a client's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record? Secondary Vascular Primary Purpuric

purpuric

Which of the following is an important function of the skin? Production of carotene Synthesis of vitamin D Protection against melanin deposits Maintenance of acid-base balance

synthesis of vitamin D

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 asthma The client has melanoma The client has chronic hypoxia The client has COPD

the client has chronic hypoxia

A client has sustained burns over 50% of the body. When planning care for this client, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.) Loss of water and electrolytes Penetration by microorganisms Mechanical or chemical injuries Regulation of body temperature Synthesis of vitamin D

Loss of water and electrolytes Penetration by microorganisms Mechanical or chemical injuries

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? Head-to-toe assessment Braden scale Newton scale Norton scale

braden scale

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 smooth Moist and rough Dry and rough Moist and smooth

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? mild high negligible moderate

high

When documenting that a client has freckles, the appropriate term to use is macules patches vesicles bullae

macules

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Limbs Palmar surfaces Eyebrows Vertex

palmar surfaces

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... dry flaking skin and dull dry hair as a result of disease. ineffective individual coping related to changes in appearance. anxiety related to loss of outdoor activities and altered skin appearance. risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions.

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

To assess an adult client's skin turgor, the nurse should use the finger pads to palpate the skin at the sternum. press down on the skin of the feet. use the dorsal surfaces of the hands on the client's arms. use two fingers to pinch the skin under the clavicle.

use two fingers to pinch the skin under the clavicle