Chapter 14: Assessing Skin, Hair & Nails
Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?
Acne
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 nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?
hypoxia
Which of the following assessment findings most likely constitutes a secondary skin lesion?
keloid formation at the site of an old incision
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 explains to the client that there is a genetic component with skin cancer, especially
malignant melanoma
Which statement by a client about the skin needs validation by the collection of objective data by the nurse?
my feet hurt and are always cold to the touch
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
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 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
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
The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as
stage II
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
Which of the following is an important function of the skin?
synthesis of vitamin d
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution
A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?
Do you feel anxious at times?
What role does oxyhemoglobin play in the physiological process that results in pallor?
the reduction of red pigment in the arteries
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
underarms
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
The nurse in a clinic is caring for a 19-year-old male client who has a new onset of vesicles around the mouth and chin. The nurse completes an assessment, reviews data collected, and is determining which condition the client is experiencing.
Herpes Simplex: Clustered, fluid-filled vesicles Cyst: Lesion that is walled off containing fluid or semisolid material Impetigo: Bullae that rupture and ooze serous fluid forming a honey-colored crust
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
I: Intact, firm skin with redness II: Ulceration involving the dermis III: Full-thickness skin loss IV: Necrosis with damage to underlying muscle
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 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
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 (type of ringworm presentation)
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast
A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings?
ask the client if they experience periods of excessive sweating
The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?
assessing the client's hard palate with a bright light
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
Recommended protective measures to avoid skin cancer include which of the following?
avoiding sun exposure
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
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
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
caused by aging of the skin in older adults
A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?
67 year old White female
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
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis
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
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
During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
existence of systemic diseases that have skin manifestations
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
fainting
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
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