HA: Integumentary
Which of the following scores on the Braden scale signifies that the patient is not at risk for pressure sores?
ANSWER: 19-23 explanation: the higher the number, the less at risk the patient is
A client presents to the health care clinic and reports the appearance of a rough texture and darkening color of the skin around the neck. The nurse knows this client should be assessed for which disease process?
ANSWER: diabetes mellitus
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
ANSWER: impetigo
The only layer of the skin that undergoes cell division is the...
ANSWER: innermost layer of the epidermis
Which of the following assessment findings most likely constitutes a secondary skin lesion?
ANSWER: keloid formation at the site of an old incision
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
ANSWER: papule
A mother brings her 4-year-old daughter to a clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds the rash is serpiginous. The nurse would know that the rash is most probably caused by
ANSWER: scabies
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?
ANSWER: small pit's in the surface of the nails
The nurse is conducting a skin assessment on a client who suffered a burn injury. The client wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?
ANSWER: superficial
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further asses the client for
ANSWER: symptoms of stress
The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?
ANSWER: vasoconstriction
A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?
ANSWER: vesicle
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?
ANSWER: vesicle
The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a...
papule
