Chapter 22: Assessment of the integument system
Identify one specific identified by the nurse during assessment of each of the patient's functional health patterns that would indicate a risk factor for skin problems or a patient response to a skin problem Health perception/health management Nutritional/metabolic Elimination Activity/exercise Sleep/rest Cognitive/perceptual Self-perception/self-concept Role/Relationship Sexuality/reproductive Coping/Stress tolerance Value/Belief
Health perception/health management- poor skin hygiene, excesive or unprotected sun exposure Nutritional/metabolic- decreaed intake of vit A, D, E, or C. malnutrition, food allergies, obesity Elimination- incontinence, fluid imbalances, pruritus Activity/exercise- exposure to carcinogens or chemical irrtants Sleep/rest- itching that interferes with sleep Cognitive/perceptual- pain, decreased perception of heat, cold, and touch Self-perception/self-concept- feelings of rejection, prejudice, self-esteem loss Role/Relationship- altered relationships with others Sexuality/reproductive- changes in sexual intimacu because of appearance, pain, treatment effects Coping/Stress tolerance- skin problems exacerbated by stress, coping strategies Value/Belief- high social value placed on appearance and skin condition with tanning, use of cosmetics, religious beliefs
The patient is visiting the free clinic to refill her medications. During the generalized assessment, the nurse documents alopecia: an increased heart rate; warm, moist, flushed skin; and thin nails. The patient also states she is anxious and has lost weight lately. Which systemic problem will the nurse most likely suspect and relate to the health care provider. a. Hyperthyroidism b. systemic lupus erythematosus c. vitamin B1(thiamine) deficiency d. Human immunodeficiency virus (HIV) infection
a
What is the most common diagnostic test used to determine a causative agent of skin infections a. Culture b. Tzanck test c. immunofluorescent studies d. Potassium hydroxide (KOH) slides
a
A woman calls the health clinic and describes a rash that has over the abdomen and chest. She tells the nurse it has raised, fluid-filled, small blisters that are distinct a. Identify the type of primary skin lesion described by this patient b. What is the distribution terminology for these lesions c. What additional information does the nurse have to document the critical components of these lesions
a. vesicles b. discrete localized to the chest and abdomen c. color, size, height, shape, configuration odor
A home health nurse is visiting an older obese woman who has recently has hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is. a. thickening of the skin b. dermatitis in the folds of her skin c. loss of color in diffuse areas of her skin d. a firm plaque caused by fluid in the dermis
b
A patient has a plaque lesion on the dorsal foreman. Which type of biopsy is most likely to be used for diagnosis of the lesion. a. punch biopsy b. shave biospy c. incisional biopsy d. excisional biopsy
b
An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo
b
The nurse observes that redness remains after palpation of a discolored lesion on the patient's leg. This finding is characteristic of a. varicosities b. intradermal bleeding c. dilated blood vessels d. erythematous lesions
b
The patient asks the nurse what telagiectasia looks like. Which is the best description for the nurse to give the patient. a. a circumscribed, flat discoloration b. small, superficial dilated blood vessels c. benign tumor of blood or lymph nodes d. Tiny purple spots resulting from tiny hemorrphages
b
When assessing an african american patient, the nurse notes ashen color of the nail beds. What should the nurse do next. a. palpate for rashes on the legs b. assess for jaundice in the sclera of the eye c. Assess the mucous membranes for cyanosis d. assess for pallor of the skin on the buttocks
c
When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? a. Increased bruising b. excess perspiration c. decreased extracellular fluid d. chronic ultraviolet light exposure
c
Priority Decision: When performing a physical assessment of the skin, what should the nurse do first. a. palpate the temperature of the skin with the fingertips b. Asses the degree of turgor by pinching the skin on the forearm c. Inspect specific lesions before performing a general examination of the skin d. ask the patient to undress completely so that all areas of the skin can be inspected
d
What is the primary difference between an excoriation and an ulcer a. Ulcers do not penetrate below the epidermal junction b. Excoriations involve only thinning of the epidermis and dermis c. Excoriations will form crusts or scabs, whereas ulcers remain open d. An excoriation heals without scarring because the dermis is not involved
d
When obtaining important health information from a patient during assessment of the skin, it is most important for the nurse to ask about a. a history of freckles as a child b. patterns of weight gain and loss c. communicable childhood illnesses d. skin problems related to the use of medications
d