Chapter 55 Assessment of Integumentary Function ML4 w/ rational

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding? It is a spider angioma that is associated with liver disease. It is a telangiectasia that is associated with varicose veins. It is an ecchymosis that is associated with trauma and bleeding. It is a cherry angioma that is a normal age-related skin alteration.

A cherry angioma is a papular and round area that is red, found on extremities, and may blanch with pressure. This lesion is considered a normal age-related skin change. A spider angioma is red with a central body and radiating branches that is associated with liver disease. A telangiectasia has a shape like a spider that is caused by the dilation of venous vessels and varicose veins. Ecchymoses are round or irregular macular lesions that vary in color and are associated with trauma or bleeding.

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? Macule Papule Plaque Patch

A flat, nonpalpable, circumscribed lesion less than 1 cm is a macule. A patch is a macule larger than 1 cm, and possibly with an irregular border. A papule is an elevated palpable solid mass with a circumscribed border and less than 0.5 cm. A plaque is a papule greater than 0.5 cm.

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? Wheal Macule Vesicle Papule

A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client? The client should consider changing careers as stress plays a significant role in this condition. Recommend the client speaks with a health care provider about curettage which is the most common treatment. Avoidance of direct sunlight with protective clothing measures should be discussed with the client. Reassure the client that the condition usually resolves if dietary restrictions limiting caffeine and alcohol are followed.

Actinic ketatosis, sometimes referred to as solar keratosis, is a plaque skin condition caused by long-term exposure to ultraviolet light. A plaque is a group of coalesced papules with a flat top. Of the choices presented, the best advice the nurse can give the client is to instruct them about preventive measures to avoid direct sun or ultraviolet light. This could prevent future breakouts since this condition can reoccur. This condition develops over a number of years and typically affects clients over 40, who work outdoors frequently, sunbath, or tan. This condition is not directly related to stress. Changing career fields is not be a practical or necessary intervention for this client. While the condition could resolve itself, the client should seek medical advice as some studies suggest a precancerous component. Dietary restrictions, limiting caffeine and alcohol do not have a direct correlation related to this condition. The most common surgical intervention is cryotherapy.

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted? Blue-green hue White patches Purple-gray cast Red coloration

Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. Inflammation in light-skinned people is noted by erythema, or redness of the skin.

The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss? Radiation Evaporation Conduction Convection

Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.

A nurse on assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement? Monitor normal variation in skin color. Lower the thermostat in the client's room. Provide addtional blankets for this client. Check the client's oral temperature.

Erythema is pink or a red skin shade that is caused by dilation of the capillaries. In clients who are more light-skinned, it is easily observable. Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema. This color may be seen when there is inflammation or fever, so checking the client's oral temperature should be the nurse's priority. Once the client's temperature is established, interventions such as lowering the thermostat in the room, providing additional blankets, and/or conducting a more detailed assessment can be determined. A change in the client's skin color should always be investigated.

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of albinism. vitiligo. anemia. local arterial insufficiency.

In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky white spots. Local arterial insufficiency is characterized by marked localized pallor.

The nurse documents the skin color change of a dark-skinned African American patient in cardiogenic shock as: Ashen gray and dull. Dusky blue. Reddish pink. Whitish pink.

In shock, vasoconstriction and hypoperfusion occur. These physiologic changes cause an ashen gray and dull appearance to the skin of a dark-skinned individual. Refer to Table 51-2 in the text.

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? Jaundice Pallor Bronzed appearance Cherry red face

Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin (>2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes.

Which cells play a role in cutaneous immune system reactions? Langerhans' cells Merkel cells Melanocytes T-lymphocytes

Langerhans' cells are accessory cells of the afferent immune system that play a role in cutaneous (skin) immune system reactions. These cells process invading antigens and transport the antigens to the lymph system to activate the T lymphocytes. Merkel cell are receptors that transmit stimuli to the axon through a chemical synapse and therefore are associated with the sense of touch. Melanocytes are the cells that give skin its pigment.

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? Freckles Yellowish waxy deposits Itchy spots Dryness

Lentigines are freckles. Xerosis is dryness. Neurodermatitis is itchy spots. Xanthelasma is the yellowish waxy deposits on the upper and lower eyelids.

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing? Atrophy Lichenification Keloid Scales

Lichenification is a thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high? Convection Conduction Radiation Evaporation

Mechanisms for heat loss from the body include convection, conduction, radiation, and evaporation. Normally all of these mechanisms are used. However, when the ambient temperature is very high, radiation and convection are ineffective. Evaporation becomes the only means for heat loss.

Which of the following pigments influences hair color? Pheromones Keratin Sebum Melanin

Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Sebum is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. Fingernails Hair Skin Endocrine glands Subcutaneous tissue

Nails are layers of hard keratin that have a protective function. The epidermis contains an outer layer of dead skin that forms a tough protective protein called keratin. Hundreds of strands of keratin link together with amino acids to form hair. Endocrine glands and subcutaneous tissue are not made of keratin.

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review? Hemoglobin and hematocrit Glucose level Arterial blood gases BUN and creatinine

Normal nails appear slightly convex with a 160° angle between the nail base and the skin. Concave-shaped nails, referred to as "spooning" because of their characteristic appearance, are a sign of iron-deficiency anemia. ABGs, BUN and creatinine, and glucose levels are not related to this shape of nail.

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as ecchymosis. spider angioma. telangiectasia. petechiae.

Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.

Petechiae are associated with which of the following disorders? Thrombocytopenia Deep vein thrombosis Pulmonary emboli Acute respiratory distress syndrome (ARDS)

Petechiae are small lesions that are red or purple in color. They are associated with broken capillaries or indicative of platelet abnormalities, specifically thrombocytopenia. Petechiae are not associated with deep vein thrombosis, pulmonary emboli, or ARDS.

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? Petechiae Ecchymoses Cherry angiomas Telangiectasias

Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.

Sudoriferous glands secrete which type of substance? Hormones Oil Cerumen Sweat

Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.

Students are reviewing information about the glands of the skin. The students demonstrate understanding of the material when they state which of the following? The eccrine glands are primarily located in the axillae. The sebaceous glands are responsible for sweat secretion. The sweat glands are responsible for lubricating the hair. The apocrine glands become active at puberty.

The apocrine glands, a type of sweat gland, become active at puberty. The sebaceous glands are responsible for lubricating the hair and rendering the skin soft and pliable. The sweat glands are responsible for sweat secretion. The apocrine glands are located in the axillae, anal region, scrotum, and labia majora.

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding? Iron deficiency anemia Long-standing cardiopulmonary disease Fungal infection Poor circulation

The concave shape of the nails, referred to as spooning, is a sign of iron deficiency anemia. Clubbing of the nails, at greater than a 160-degree angle, suggests long-standing cardiopulmonary disease. Nails thicken when there is a fungal infection and poor circulation.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Epidermis Dermis Papillary layer Stratum corneum

The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lies directly beneath the epidermis.

Three female students share an apartment. They notice after several months that their menstrual cycles are coordinating. What is speculated to be responsible for the synchronization of their monthly cycles? eccrine secretions sebaceous secretions pheromone secretions apocrine secretions

The function of apocrine secretions in humans is unknown, although the onset of secretions coincides with puberty. Some speculate that synchronization of menstruation among women in close living conditions such as a dormitory room is the result of apocrine secretions, but evidence for this phenomenon is mostly anecdotal.

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as vesicles. wheals. pustules. cysts.

The lesions form herpes zoster are vesicles, defined as circumscribed, elevated, palpable masses that contain serous fluid and are less than 0.5 cm in diameter. Wheals are elevated masses with transient, irregular borders. Pustules are pus-filled lesions. Cysts are encapsulated fluid-filled or semisolid masses in the subcutaneous tissue or dermis.

Which factor causes wrinkles among older adults? Decrease in melanin Loss of subcutaneous tissue Decrease in estrogen production Decrease in sebum

The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.

The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding? Alopecia Hirsutism Jaundice Hyperpigmentation

The nurse anticipates finding hirsutism, or excessive hair growth, as Cushing syndrome causes hirsutism, especially in women. Alopecia, jaundice, and hyperpigmentation are not typical assessment findings in clients with Cushing syndrome.

When assessing a patient's skin, the nurse would use palpation to assess which of the following? Color Moisture Texture Turgor

The nurse assesses turgor using palpation. Observation is used to assess color, moisture, and texture.

Which of the following observations helps the nurse in determining adequate oxygenation? Pink nail beds Capillary refill time Hard keratin Appearance of lunula

The nurse observes the color of the nail beds. Pink nail beds suggest adequate oxygenation. Lunula does not signify adequate oxygenation. Fingernails and toenails are layers of hard keratin that have a protective function. Hence, hard keratin does not signify adequate oxygenation. Capillary refill time is an assessment for tissue perfusion.

The epidermis consists of four layers as listed below. Place the layers in the proper order from outermost to innermost. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Stratum corneum 2Stratum lucidum 3Stratum granulosum 4Stratum germinativum

The outermost layer of the epidermis is the stratum corneum. This is followed by the stratum lucidum, stratum granulosum, and finally, the stratum germinativum, the innermost layer.

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? "Have you been ingesting large quantities of alcohol?" "Have you been diagnosed with Addison's disease?" "Have you been in the sun a lot?" "Have you been eating a large amount of carotene-rich foods?"

The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods.

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding? Pearly white substance that is attached to the hair shaft that is not removed with brushing Sparse hair, white in color Dry, brittle hair Knots in hair when brushed

The pearly white substance that is attached to the hair shaft is indicative of nits or head lice and should be reported to the physician so treatment can be administered. The other findings are not abnormal in the older adult client.

Production of melanin is controlled by a hormone secreted by which of the following? Hypothalamus Thyroid Adrenal Parathyroid

The production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. Production of melanin is not controlled by the thyroid, adrenal, or parathyroid gland.

Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate? Thighs Eyebrows Beard Axillae

The rate of hair growth varies. Beard growth is the most rapid, followed by hair on the scalp, axillae, thighs, and then eyebrows.

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? Reduction in sebum production Reduction in the elasticity of the skin Reduction in melanin production Reduction in estrogen production

The sebum is a lubricant that prevents the drying and the cracking of the skin and hair. Due to aging, the skin becomes dry and flaked as sebum production is reduced. Loss of elasticity of the skin causes wrinkles among older adults. Reduction in melanin results in gray hair. Facial hair and sometimes chest hair appear in postmenopausal women as a result of the decreased production of estrogen.

When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water? Stratum corneum Stratum lucidum Stratum granulosum Stratum germinativum

The stratum corneum, the outermost layer of the epidermis, has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture in the subcutaneous tissues. The other layers do not have this capacity.

Which layer of the skin is made of primarily adipose tissue? Epidermis Dermis Hypodermis Muscle

The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones. The epidermis is the external layer of the skin. The dermis is made up of blood, lymph vessels, nerves, sweat and sebaceous glands, and hair roots.

Which layer of the skin is made of primarily adipose tissue? Hypodermis Dermis Epidermis Muscle

The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones. The epidermis is the external layer of the skin. The dermis is made up of blood, lymph vessels, nerves, sweat and sebaceous glands, and hair roots.

The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based? Rash Eczema Xanthelasmas Seborrheic keratosis

There are some skin conditions that are genetically based. Eczema is one such condition that does not have a distinct inheritance pattern but does have a genetic predisposition for the condition. Rash is not considered a genetically based skin condition. Xanthelasmas or yellowish waxy deposits on the upper and lower eyelids and seborrheic keratoses or crusty brown patches are both considered benign skin changes in the skin of an older adult.

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced? Conduction Convection Evaporation Radiation

Three major physical processes are involved in loss of heat from the body to the environment. The first process—radiation—is the transfer of heat to another object of lower temperature situated at a distance. The second process—conduction—is the transfer of heat from the body to a cooler object in contact with it. The third process—convection, which consists of movement of warm air molecules away from the body—is the transfer of heat by conduction to the air surrounding the body.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? Sebum deficiency Fluid retention Dehydration Protein deficiency

Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? Vesicles Bullae Cysts Pustules

Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions.

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? Vitiligo Hirsutism Lichenification Telangiectases

Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.

Which term refers to a condition characterized by the destruction of melanocytes in circumscribed areas of the skin? Vitiligo Hirsutism Lichenification Telangiectases

Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply. Wound size Periwound skin Wound bed Pattern of eruption

When documenting an acute open wound, the nurse should consider the wound's size, the condition of the periwound skin (skin surrounding the wound), a description of the wound bed, and the wound edges and margins. The pattern of eruption relates to the patterns of lesions on a client's skin and does not apply to an acute open wound.

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? Apply a special dye to the area. Make sure that the room is darkened. Protect the patient from the light. Obtain samples of the lesion by scraping.

When performing a Wood's light examination, the nurse would need to ensure that the room is darkened to allow visualization of the fluorescent light so that he or she can differentiate epidermal from dermal lesions. Dye is used for immunofluorescence. There is no need to protect the patient from the light. Skin scrapings involve obtaining samples of the lesion.

Which diagnostic test is used to examine cells from herpes zoster? Tzanck smear Skin scrapings Patch testing Skin biopsy

A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scraping is used to diagnose spores and hyphae. A patch test is used to identify substances to which the client has developed an allergy.

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding? It is a spider angioma that is associated with liver disease. It is a telangiectasia that is associated with varicose veins. It is an ecchymosis that is associated with trauma and bleeding. It is a cherry angioma that is a normal age-related skin alteration

A cherry angioma is a papular and round area that is red, found on extremities, and may blanch with pressure. This lesion is considered a normal age-related skin change. A spider angioma is red with a central body and radiating branches that is associated with liver disease. A telangiectasia has a shape like a spider that is caused by the dilation of venous vessels and varicose veins. Ecchymoses are round or irregular macular lesions that vary in color and are associated with trauma or bleeding.

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following? Macule Patch Papule Plaque

A flat, nonpalpable, circumscribed lesion less than 1 cm is a macule. A patch is a macule larger than 1 cm, and possibly with an irregular border. A papule is an elevated palpable solid mass with a circumscribed border and less than 0.5 cm. A plaque is a papule greater than 0.5 cm.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? Macule Vesicle Pustule Cyst

A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Scale Crust Ulcer Scar

A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Ulcer Scar Scale Crust

A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? Erosion Pustule Cyst Spider angioma

A spider angioma is a vascular lesion. Erosion is a secondary lesion. Pustules and cysts are classified as primary skin lesions.

Which of the following describes a total absence of pigment melanin? Albinism Vitiligo Anemia Cyanosis

Albinism is the total absence of the pigment melanin. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of the skin. Anemia is a decreased hematocrit. Cyanosis occurs from a increased amount of deoxygenated blood.

A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars? Rheumatoid nodules Calluses Senile keratosis Senile lentigines

Areas of skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin. Senile keratosis is small, yellow or brown raised lesions that appear on the face and trunk in an older adult client. Senile lentigines are also known as liver spots and are found on the hands and forearms of older people. Rheumatoid nodules affect those clients with rheumatoid arthritis.

A nurse is performing a skin assessment on a client with diabetes and notes furuncles and carbuncles to both lower legs. The client states their skin typically has "issues" but eventually heals if left alone. Which of the targeted teaching topics would most benefit this client? Discuss treatment concerning bacterial infections, blood glucose levels, and basic skin maintenance techniques. Review signs and symptoms of fungal infections, short acting insulin management, and wound debridement measures. Discuss treatment options for kaposi sarcoma, topical skin treatments, weight control measures, and adherence. Review of altered integumentary function related to diabetes, managing dermatophyte infections, and dietary restrictions.

Bacterial infections may appear as small pimples around hair follicles (folliculitis). The most frequently affected sites include the lower legs, lower abdomen, and buttocks. Sometimes these lesions enlarge to become furuncles or carbuncles. The skin of clients with diabetes is prone to bacteria and fungal infections. If the blood glucose level is not well controlled, these infections may be very slow to heal. Nurses must be alert to the signs and symptoms of these common infections and help the client or family learn basic skin maintenance techniques. Fungal infections are quite common in areas that remain moist, such as under the breast and the upper thighs. Candida infections appear beefy red and often have pustules around the border of the area with the skin appearing moist and raw. Dermatophyte infections are dry and only minimally red, with more scaling. Common sites are the toenails and feet. Kaposi sarcoma Is a skin condition associated with the human immune deficiency virus (HIV) and lesions are seen on the the skin, lymph nodes, internal organs and mucous membranes, and the linings of the mouth and nose and throat. Not enough information is provided about the client to specifically discuss insulin management, wound treatments, weight, and dietary management concerns. A review of altered integumentary function in regards to diabetes is too broad a discussion.

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? Skin scraping Tzanck smear Patch test Biopsy

Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scrapings are used to diagnose spores and hyphae. A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster. A patch test is used to identify substances to which the client has developed an allergy.

The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing? Anemia Carbon monoxide poisoning Polycythemia Shock

Cherry red nail beds, lips, and oral mucosa in a dark-skinned person are signs of carbon monoxide poisoning.

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? Anemia Hypoxia Local trauma Psoriasis

Clubbing is an indication of hypoxia, which may be the result of the patient's chronic respiratory illness. Severe iron-deficiency anemia may be indicated by spoon-shaped nails. Beau's lines, transverse depressions of the nail, suggest local trauma. Pitted nails indicate psoriasis.

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease? Telangiectasia Ecchymosis Fluid-filled vesicles Purplish cutaneous lesions

Cutaneous signs may be the first manifestation of human immunodeficiency virus (HIV), appearing in more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with low CD4 counts and may become very atypical in immunocompromised people. Some disorders such as Kaposi's sarcoma (presenting as palpable lesions that can be purple), oral hairy leukoplakia, facial molluscum contagiosum, and oral candidiasis may suggest that CD4 counts are less than 200 to 300 cells/mcL.

A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response? "Earwax is made by glands in your ears." "The amount of earwax lessens with aging." "To eliminate cerumen, flush the ears with water when you shower." "More earwax is made when an infection is present."

Earwax or cerumen is made by specialized apocrine glands called ceruminous glands, which are found in the external ear where they produce cerumen or wax. There is no evidence that the amount of earwax lessens with aging. Flushing the ears with water when showering will not reduce the amount of cerumen produced. There is no evidence that cerumen increases when an infection is present.

The nurse is instructing unlicensed personnel on gerontologic considerations of the skin. The nurse finds that the participants understand the instructions when they know that the elderly are at a higher risk for shear injuries due to loss of rete ridges. loss of subcutaneous tissue. decreased capillary loops. sun damage over time.

Elderly clients are at a higher risk for shear injuries due to loss of rete ridges from thinning at the junction of the dermis and epidermis. The loss of anchoring sites between the two skin layers enables even minor injury/stress to the epidermis to cause it shear away from the dermis. The other answers do not apply.

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: Palpable, solid tumors >3 cm. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Flat, mole-like lesions. Flat macules with irregular borders.

Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. Flat, mole-like lesions. Palpable, solid tumors >3 cm. Flat macules with irregular borders.

Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? Oral mucosa Fingernails Sclera Nose

In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjunctivae, oral mucosa, and nail beds.

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? Sclera Oral mucosa Fingernails Nose

In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjunctivae, oral mucosa, and nail beds.

Which type of cell is believed to play a significant role in cutaneous immune system reactions? Merkel cells Langerhans cells Melanocytes Phagocytes

Langerhans cells are common to the epidermis and are accessory cells of the afferent immune system process. Merkel cells are receptor cells in the epidermis that transmit stimuli to the axons via a chemical response. Melanocytes are special cells of the epidermis that are primarily involved in producing melanin, which colors the hair and skin. Phagocytes are white blood cells that engulf and destroy foreign materials.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? Bronze Yellow Gray Orange-green

Patients diagnosed with Addison's disease have a bronzed appearance, an "external tan." Yellowish skin is noted in the patient diagnosed with jaundice. Patients with renal failure may have a gray or orange-green cast to the skin.

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule? Skin biopsy Skin scrapings Tzanck smear Patch test

Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens, such as nickel or fragrances, to normal skin under occlusive patches. Patients wear these occluded strips on their backs for 48 hours, and the area is assessed after 72 hours.

A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum? prevents drying and cracking of the skin and hair cooling overwarm skin trapping debris in the external ear contributing to acidity of perspiration to decrease microbial growth

Sebum, which is an oily lubricant, prevents drying and cracking of the skin and hair.

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present? The skin is ashen gray and dull. The skin is dusky blue. The skin is reddish pink. The skin is whitish pink.

Shock due to decreased perfusion and vasoconstriction is indicated in dark skin as an ashen gray, dull appearance.

The nurse is assessing a client who was a victim of a house fire. Which finding indicates to the nurse that the client may have carbon monoxide poisoning? Ruddy blue face Dusky blue nail beds Yellow tinge to the forehead Cherry red lips

Skin color changes can occur with different health conditions. Cherry red lips indicate carbon monoxide poisoning. A ruddy blue face is associated with polycythemia. Dusky blue nail beds are associated with cyanosis. A yellow tinge to the forehead is associated with carotenemia.

An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned about melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of? Senile keratoses Senile lentigines Melanoma Freckles

Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.

The purpose of melanin is to: determine skin color. form a callus where the skin is subjected to friction. assist in transfer of heat through contact. prevent drying and cracking of the skin and hair.

The color of the skin is determined by a pigment called melanin, which is manufactured by melanocytes located in the epidermis. A callus is a thick layer of epidermal cells that forms in response to recurring friction on an area of skin. Conduction is the transfer of heat through contact. Sebum prevents drying and cracking of the skin and hair.

Which term refers to a condition characterized by the destruction of melanocytes in circumscribed areas of the skin? Lichenification Telangiectases Vitiligo Hirsutism

Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? Liver spots Dark discoloration of the skin Bright red moles Yellowish waxy deposits on the eyelids

Xanthelasma is a common, benign manifestation of aging skin, or it can sometimes signal hyperlipidemia. Solar lentigo refers to liver spots. Melasma refers to dark discoloration of the skin. Cherry angioma is the term used to describe a bright red mole.