Chapter 9 prepu

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? Repeated sunburns in childhood may explain the presence of some of your moles. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

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

Distribution

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? Assess the client for changes in sensation due to vascular problems Monitor the client for additional findings of cystic fibrosis Suggest that the client use antiperspirant products Document the findings in the client's record as normal

Document the findings in the client's record as normal

The nurse is preparing to examine a client's skin. What would the nurse do next? Ensure that the room is hot to prevent chilling. Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Have the client remove clothing from the upper body.

Expose only the body part that is being examined.

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment? Tenting indicates dehydration Tenting indicates malnutrition Tenting indicates dramatic weight loss Tenting indicates vitamin B12 deficiency

Tenting indicates dehydration

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. entire skin surface. soles of the feet. adipose tissue.

areola of the breast.

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

vellus.

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? 1 2 3 4

3

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? Oxygen deficiency Acute illness Psoriasis Trauma

Acute illness

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? Are you allergic to foods, medications, or other substances? "Does anyone else in your family have a rash like this?" "Have you ever had a rash like this before?" "What have you been doing to control the itching?"

Are you allergic to foods, medications, or other substances?

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 "ABCD" characteristic of malignant melanoma? Asymmetrical shape Borders well demarcated Color is uniform Diameter less than 6mm

Asymmetrical shape

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? Newton scale Head-to-toe assessment Norton scale Braden scale

Braden scale

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

Carotene

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for? Linear Annular Clustered Discrete

Clustered

The nurse notes that a 30-year-old female has hair on the chin and upper lip. What should the nurse consider as causing this growth of facial hair? Select all that apply. Cushing disease Undiagnosed diabetes Side effect of steroid use Polycystic ovary syndrome Vitamin B-complex deficiency

Cushing disease Side effect of steroid use Polycystic ovary syndrome

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process? Iron deficiency anemia Cushing's disease Basal cell carcinoma Lupus erythematosus

Cushing's disease

When the nurse is inspecting a client's fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer? Epidermal Sebaceous Subcutaneous Dermal

Dermal

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? Stratum corneum Stratum lucidum Dermis Epidermis

Dermis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer

Dermis

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? Hypoxia Infection A normal finding Vitamin C deficiency

Hypoxia

The RN should intervene and further educate the nursing assistant when observing which action? Independently pulling an immobile client up in bed Assisting feeding a client ground chicken with dentures in place Ambulating a client using a walker in the hallway Propping a client on the side using pillows under the hip, knees, and shoulder

Independently pulling an immobile client up in bed

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? Document the benign findings. Perform a random blood sugar test. Ask the client about a family history of cancer. Refer the client for medical follow-up.

Perform a random blood sugar test.

When educating a client about the risks of malignant melanoma, what would you know to include? (Mark all that apply.) Red or light hair Freckles Immunosuppression Female gender Age older than 60

Red or light hair Freckles Immunosuppression

The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse? Renal failure Cardiovascular failure Hepatic failure Respiratory failure

Renal failure

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous cells Sweat glands Subcutaneous tissue Sebum production

Sebum production

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? Stage I Stage II Stage III Stage IV

Stage II

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? Stage I Stage II Stage III Stage IV

Stage II

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

The client has chronic hypoxia

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? The client's current medication regimen The client's ability to change position The pigmentation of the client's skin The client's history of integumentary disorders

The client's ability to change position

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? There is a non-blanching reddened area on the client's coccyx region. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. There is noticeable bruising on and around the client's coccyx region. There is a generalized rash on the client's lower back and buttocks.

There is a non-blanching reddened area on the client's coccyx region.

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? Multiple nevi Tinea versicolor Herpes simplex Tinea corporis

Tinea corporis

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash? Insect bites Urticaria or hives Psoriasis Purpura

Urticaria or hives

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 mild moderate negligible

high

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 hypoxia. trauma. anemia. infection.

hypoxia.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. intact, firm skin with redness necrosis with damage to underlying muscle ulceration involving the dermis full-thickness skin loss

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

The nails, located on the distal phalanges of the fingers and toes, are composed of ectodermal cells. endodermal cells. keratinized epidermal cells. stratum cells.

keratinized epidermal cells.

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

macules.

A dark-skinned client 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 abdomen. arms. legs. sclera.

sclera.

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 I. stage II. stage III. stage IV.

stage II.

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: symptoms of stress. recent radiation therapy. pigmentation irregularities. allergies to certain foods.

symptoms of stress.

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

use two fingers to pinch the skin under the clavicle.