Chapter 9: The Integumentary System

When inspecting the hair, what would the nurse note? (Select all that apply.) Color Condition of hair shaft Length of hair Hair breakage of more than 6 hairs Hair shafts that are shiny

Color Condition of hair shaft Hair shafts that are shiny

The student nurse learns that examining the skin can do all of the following except? Reveal overhydration Allow early identification of neurologic deficits Identify physical abuse Allow early identification of potentially cancerous lesions

Allow early identification of neurologic deficits

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

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? "Does nail biting run in your family?" "Have you always bitten your nails?" "Have you been depressed lately?" "Do you feel anxious at times?"

Do you feel anxious at times?"

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? Moist and smooth Moist and rough Dry and smooth Dry and rough

Dry and rough

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.

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. Complete the table of possible conditions by choosing from the list of assessment findings.

Herpes simplex :Clustered, fluid-filled vesicles Cyst : Lession that is walled off containing fluid or semisolid material Impetigo: Bullae that rupture or oozues serious fluid forming a honey-colored crust

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? Diabetes mellitus Hypothyroidism Crohns disease Cushing disease

Hypothyroidism

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? Nodule Papule Vesicle Macule

Macule

A 5-year-old African American boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color? Capillary blood flow Carotene Melanin Collagen

Melanin

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

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

A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?

Pressure Ulcer 3

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

Pressure ulcer

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Cherry angioma Cutaneous horn Seborrheic keratosis Pressure ulcer

Pressure ulcer

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? Transverse white lines in the nails Beau's lines White spots, or leukonychia, on the nail surfaces Small pits in the surfaces of the nails

Small pits in the surfaces of the nails

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 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 II

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

Synthesis of vitamin D

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client has a full-time caregiver. The client is consistently incontinent of urine. The client has a surgical diagnosis. The client adheres to a vegetarian diet.

The client is consistently incontinent of urine.

A 4-year-old child is present at 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.

What is the most important focus area for the integumentary system? UV radiation exposure Chemical exposure Moles with defined borders smaller than 6 mm Washing the face and hands

UV radiation exposure

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? Vitiligo Striae Angiomas Albinism

Vitiligo

A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown? a 49-year-old female with a long history of Parkinson disease who walks with a cane a 75-year-old male with left-sided hemiparesis who is ambulatory with a quad walker a 66-year-old female who underwent hip surgery 2 days ago and is working with physical therapy a 30-year-old male who sustained a spinal cord injury who is now paraplegic

a 30-year-old male who sustained a spinal cord injury who is now paraplegic

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis.

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? alopecia folliculitis ringworm tinea capitis

folliculitis

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.

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 I. stage II. stage III. stage IV.

stage II.

Connecting the skin to underlying structures is/are the papillae. sebaceous glands. dermis layer. subcutaneous tissue.

subcutaneous tissue.

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.

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

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 nodules. bullae. vesicles. wheals.

vesicles.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the clients.

oral mucosa.

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? Seborrhea Contact dermatitis Eczema Psoriasis

Psoriasis

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse? "Do you know how to check for signs of skin cancer?" "Sometimes moles change as you age." "When did you notice the change?" "How has it changed?"

"How has it changed?"

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?

3

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? "These are considered a normal age-related change in the skin." "It means you have skin cancer and need to have them removed." "These areas need to be cleansed daily and covered with a dry gauze bandage." "I will report these to the health care provider so that medication can be prescribed."

"These are considered a normal age-related change in the skin."

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

1 intact, firm skin with redness 2 ulceration involving the dermis 3 full-thickness skin loss 4 necrosis with damage to underlying muscle

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized? A neuropathic ulcer can develop without feeling it. Skin collagen decreases with age. Wound healing becomes prolonged with age. Hydration alters skin turgor.

A neuropathic ulcer can develop without feeling it.

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply. Asymmetrical Flat Change in size Itching Bleeding of a mole Regular borders

Asymmetrical Change in size Itching Bleeding of a mole

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action? Lower the head of bed and pull the client up with both arms. Place the client in Trendelenburg so the client can slide up in bed. Call for help and use the draw sheet to move the client. Push the client toward the head of the bed to prevent back injury.

Call for help and use the draw sheet to move the client.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? May affect a person's body image negatively Can be caused by an underlying systemic illness Local irritation can cause damage to the nail bed Abnormalities may be a sign of poor hygiene

Can be caused by an underlying systemic illness

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client? Hirsutism Rapid heart rate Sensitivity to cold Muscle cramps

Hirsutism

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

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse? "It will probably take about 12 months to totally replace a fingernail." "It takes about 6 months to totally replace a fingernail." "It will only take about a week for it to fully regrow." "It will grow back in time, but may never be the same."

It takes about 6 months to totally replace a fingernail."

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis

Keloid formation at the site of an old incision

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 Involved in digestion of food Protects against damage to the body from sunlight Circulates blood throughout the body Helps make vitamin D in the body Aids in maintaining body temperature

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

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 interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? To determine the clients risk for pressure ulcers To determine the clients risk for skin cancer To determine the clients risk for dehydration To determine the clients risk for herpes zoster

To determine the clients risk for pressure ulcers

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 signs of an infectious process. caused by aging of the skin in older adults. precancerous lesions. signs of dermatitis.

caused by aging of the skin in older adults.