CPU Chapter 9: The Integumentary System

A decrease in oxyhemoglobin will result in documentation of pallor. True or False

True

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? A. Diameter less than 1/8 of an inch B. Color is uniform C. Asymmetrical shape D. Borders well demarcated

C. Asymmetrical shape Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.

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

D. caused by aging of the skin in older adults. Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs? a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter > 6 mm; e = evolution

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution

What is the rationale for asking the client whether he or she has noticed any new or changed moles? A. The appearance of new moles is a sign of vitamin D deficiency. B. Changes in existing moles or the appearance of new moles can indicate melanoma. C. Excessive eccrine sweat gland production can cause the emergence of a new mole. D. Transition from pustules to moles can indicate psoriasis

B. Changes in existing moles or the appearance of new moles can indicate melanoma. Assessment of moles, both by client and clinician, is important in the early detection of melanomas. Moles are not a relevant finding in cases of psoriasis, vitamin D deficiency, and excess sweat production.

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. The client denies the use of any new shampoos, or other hair care products; no new medications. The nurse should ask the client questions related to the onset of which disease process? A. Crohn's disease B. Diabetes mellitus C. Hypothyroidism D. Liver disease

C. Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. Diabetes is a problem with glucose regulation. Crohn's disease is an inflammatory process in the large intestines. Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? A. Move on to next body system B. Ask further questions C. Inspect the area D. Document the statement

C. Inspect the area If the client has a specific concern about the skin, the nurse should inspect the area/lesion first and ask other questions second. It would not be appropriate to ask further questions, document the statement, or move on to the next body system until the lesion has been inspected.

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 necrosis with damage to underlying muscle 3 ulceration involving the dermis 4 full-thickness skin loss

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

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask? "Has anyone in your family ever been diagnosed with skin cancer?" "Do you take steroid medications on a regular basis?" "What dietary supplements do you usually take?" "Have you ever been assessed for diabetes?"

"Do you take steroid medications on a regular basis?" Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 15 9 13 11

15

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? 13 to 18 10 to 12 19 to 23 9 or lower

19 to 23 Levels of risk for developing pressure ulcers are rated according to the following scores: • 19 to 23: not at risk • 15 to 18: mild risk • 13 to 14: moderate risk • 10 to 12: high risk • 9 or lower: very high risk

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

A Stage I pressure ulcer has intact skin with nonblanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

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

A. "These are considered a normal age-related change in the skin." Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.

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? A. Clustered B. Linear C. Annular D. Discrete

A. Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.

A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process? A. Diabetes mellitus B. Hypothyroidism C. Psoriasis D. Contact dermatitis

A. Diabetes mellitus The appearance of a rough and dark skin around the neck area, especially in African Americans, can be an indication of diabetes mellitus. This condition is called acanthosis nigricans. Psoriasis is a skin condition caused by overgrowth of desquamated, dead epithelium skin cells and causes a silvery white appearance to the skin. Hypothyroidism causes a generalized dryness to the skin. Contact dermatitis is a thickening and roughness of the skin caused by exposure to a substance that is an allergen, chemical, foods, or emotional stress.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? A. Distribution B. Arrangement C. Colour D. Type

A. Distribution The given terms denote anatomic location, or distribution, of skin lesions over the body.

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

A. Expose only the body part that is being examined. When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings? A. The patient may have been abused. B. The patient may have a cognitive deficit. C. The patient is elderly. D. The patient may have peripheral vascular disease.

A. The patient may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of A. fissures. B. ulcers. C. erosion. D. scales.

A. fissures. Fissures are linear cracks in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete's foot.

Squamous cell carcinoma is associated with A. overall amount of sun exposure. B. precursor lesions. C. intermittent exposure to ultraviolet rays. D. an increase in the rates of melanoma.

A. overall amount of sun exposure Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a A. papule. B. macule. C. plaque. D. patch.

A. papule. Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance? Marfans syndrome Cushings syndrome Parkinsons disease Alcoholism

Alcoholism A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinsons disease is associated with stiff, rigid movements. Marfan;s syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing;s syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump).

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behaviour at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? Traction alopecia Trichotillomania Alopecia areata Tinea capitis

Alopecia areata This is a typical description for alopecia areata. There are no risk factors for trichotillomania or traction alopecia. The physical examination is not consistent with tinea capitis, because the skin is intact.

The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash? A. High blood pressure B. Allergic reaction C. Insufficient protein intake D. Low fluid volume

B. Allergic reaction Contact dermatitis occurs as an inflammatory response to an antigen. Contact dermatitis is not caused by low fluid volume, high blood pressure, or an insufficient intake of protein.

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? A. Stratum corneum B. Dermis C. Stratum lucidum D. Epidermis

B. Dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

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

B. Dermis The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition? A. Chest and abdomen B. Fingers and toes C. Nose and earlobes D. Around the mouth and lips

B. Fingers and toes Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash? A. It should not cause any problems. B. It is likely to be related to her lupus. C. It is likely to be related to an allergic reaction. D. It is likely to be related to an exposure to a chemical.

B. It is likely to be related to her lupus. A "palpable purpura" is usually associated with a vasculitis. This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and mimic many other diseases. While allergic and chemical exposures may be a possible cause of the rash, this client's SLE should make the nurse consider vasculitis.

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

B. Pressure ulcer An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? A. Alopecia, dermatitis, chemotherapy B. Psoriasis, fungal infections, trauma C. Eczema, melanoma, herpes zoster D. Vitiligo, hirsutism, vitamin deficiency

B. Psoriasis, fungal infections, trauma Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

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? A. Respiratory failure B. Renal failure C. Cardiovascular failure D. Hepatic failure

B. Renal failure Uremic frost is a sign of marked renal failure. This appearance results from precipitation of renal urea and nitrogen waste products through sweat onto the skin. Uremic frost is not related to cardiovascular failure, hepatic failure, or respiratory failure.

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? A. The pigmentation of the client's skin B. The client's ability to change position C. The client's current medication regimen D. The client's history of integumentary disorders

B. The client's ability to change position The Braden Scale appraises the client's level of mobility but does not directly include data related to medications, history of skin disorders, or pigmentation.

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? A. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. B. There is a nonblanching reddened area on the client's coccyx region. C. There is a generalized rash on the client's lower back and buttocks. D. There is noticeable bruising on and around the client's coccyx region.

B. There is a nonblanching reddened area on the client's coccyx region. Nonblanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

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? A. "How painful is your rash?" B. "What have you been doing to control the itching?" C. "Are you allergic to foods, medications, or other substances?" D. "Does anyone else in your family have a rash like this?"

C. "Are you allergic to foods, medications, or other substances?" The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information, such as a history of a previous or similar rash, pain, and measures taken to address the itching.

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? A. Dry and smooth B. Moist and smooth C. Dry and rough D. Moist and rough

C. Dry and rough A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what? A. Reynaud disease B. Neurofibromatosis C. Peripheral cyanosis D. Central cyanosis

C. Peripheral cyanosis Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the patient. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

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? A. Subcutaneous tissue B. Sweat glands C. Sebum production D. Squamous cells

C. Sebum production Sebum production decreases with age, therefore increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue.

A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response? A. Acne is caused by enlarged apocrine glands B. Acne is caused by the apocrine glands C. Acne is caused by decreased activity of the sebaceous glands D. Acne is caused by the impedance of sebum secretion onto the skin's surface

D. Acne is caused by the impedance of sebum secretion onto the skin's surface As children approach puberty, the apocrine glands enlarge and become active. At puberty, sebaceous glands increase activity, resulting in large amounts of sebum secreted into the hair follicles of the face, neck, chest, and back. Anything impeding sebum secretion onto the skin's surface may result in the formation of closed comedones and ultimately acne.

Recommended protective measures to avoid skin cancer include which of the following? A. Knowing signs of skin cancer B. Performing monthly skin self-examinations C. Seeking biannual examination by a clinician after age 40 years D. Avoiding sun exposure

D. Avoiding sun exposure While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

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

D. Cushing's disease Hirsuitism, or facial hair, on females is a characteristic feature of Cushing's disease due to an imbalance of adrenal hormones. Iron deficiency anemia may cause loss of hair but not excessive hair. Carcinoma of the skin causes lesions but not facial hairs. Lupus erythematosus causes patchy skin loss but does not cause excessive facial hair.

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? A. Multiple nevi B. Tinea versicolor C. Herpes simplex D. Tinea corporis

D. Tinea corporis In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

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. 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 Circulates blood throughout the body Involved in digestion of food

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

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

Immunosuppression Freckles Red or light hair Risk factors for melanoma: history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sunexposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack? Sclera Palms Oral mucosa Nail beds

Oral mucosa Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists it may indicate systemic hypoxemia. Peripheral cyanosis that results from vasoconstriction would most likely be noted in the nailbeds and conjunctival areas.

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 Pityriasis rosea Eczema Tinea infection

Psoriasis This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

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 adheres to a vegetarian diet. The client has a surgical diagnosis. The client is consistently incontinent of urine. The client has a full-time caregiver.

The client is consistently incontinent of urine. The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

Wheal A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. An erosion is a loss of superficial epidermis that does not extend to the dermis.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? A. Wood's light B. Sunlight C. Flashlight D. Artificial light

Wood's light

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. stage III. stage IV. stage I.

stage II. Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

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

symptoms of stress. Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.

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 1 4 2

3 A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

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

B. vellus. Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

Hair follicles, sebaceous glands, and sweat glands originate from the A. keratinized tissue. B. epidermis. C. dermis. D. eccrine glands.

C. dermis. The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

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? A. heart sounds B. body temperature C. pulse oximetry D. bowel sounds

C. pulse oximetry A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient? Cystic acne Pustular acne Chickenpox Bullous impetigo

Pustular acne Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin B12. C. D. A.

D The skin is the largest organ of the body. It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

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

D. UV radiation exposure Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

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? A. Insect bites B. Purpura C. Psoriasis D. Urticaria or hives

D. Urticaria or hives This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

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

D. areola of the breast. The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply. Keep to the established care plan Document the findings Notify the physician Evaluate the client's outcomes Modify nursing interventions

Evaluate the client's outcomes Modify nursing interventions The nurse evaluates care according to the developed client outcomes, thereby reassessing the client and continuing or modifying the interventions as appropriate. The care plan is a guide, something that changes with the client's status. There is no need to notify the physician. Documenting findings needs to be done, but it does not improve the client's outcome.

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

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) asymmetry notched border diameter great than 6 cm pink color

asymmetry notched border diameter great than 6 cm

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of infectious conditions. hypoparathyroidism. hyperthyroidism. hypothyroidism.

hypothyroidism Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) Size Other lesions on body Texture Location Depth

location size texture A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or the depth of the lesion.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by ticks allergies lice scabies

scabies

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

subcutaneous tissue

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

use two fingers to pinch the skin under the clavicle. To assess turgor, gently pinch the skin over the clavicle with two fingers.

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. nodules. bullae. wheals.

vesicles. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

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

B. Carotene Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.

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? A. Seborrhea B. Psoriasis C. Contact dermatitis D. Eczema

B. Psoriasis

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? A. Continuous trauma B. Decreased subcutaneous tissue C. Excessive collagen formation D. Inadequate circulation

C. Excessive collagen formation Keloids are caused by excessive collagen formation during the healing process, not from continuous trauma, decreased subcutaneous tissue, or inadequate circulation.

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? A. Angiomas B. Albinism C. Vitiligo D. Striae

C. Vitiligo Vitiligo is characterized by discrete areas of depigmentation. Albinism is a generalized absence of pigment, and striae are often known as stretch marks. Angiomas are small, raised skin lesions.

A client is diagnosed with paronychia. Which part of the diagram should the nurse assess for this health problem?

Paronychia is an infection of the cuticle. That is the area on the diagram that is affected.

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

The client has chronic hypoxia Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.