integumentary system PU
The client 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
A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings?
Ask the client if they experience periods of excessive sweating.
During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?
Iron deficiency anemia
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 is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?
Superficial
The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown?
Skin that feels boggy on palpation
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?
Vesicle
A hospitalized 70-year-old client with a long history of type 2 diabetes reports a decreased sensation in their lower extremities. What is the best response by the nurse?
"It sounds like you have developed peripheral neuropathy."
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 takes about 6 months to totally replace a fingernail."
The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?
Look for information from family and records regarding any problems that may have occurred at least 3 months ago.
An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding?
Papule
While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?
Petechiae
While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?
Petechiae
A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?
Pinch a fold of skin on the client's forearm.
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
Small pits in the surfaces of the nails
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?
Small pits in the surfaces of the nails
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?
Vesicle
A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown?
a 30-year-old male who sustained a spinal cord injury who is now paraplegic
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness.
A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?
advanced lung disease
A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?
increased body and facial hair
A client with a zosteriform rash has a rash that
is distributed along a dermatome
The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as:
vitiligo.
Squamous cell carcinoma is associated with
overall amount of sun exposure.
The nurse is assessing a client exhibiting round, red and purple macules that are approximately 1 to 2 mm in size. The nurse should document which type of vascular skin lesion?
petechiae
A mother brings her 5-year-old son who is of African descent to the clinic. The mother is concerned about recent changes in her child's hair color from black to a copper-red. What is the best response by the nurse?
"This could be a sign of malnutrition."
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
Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?
19 to 23
The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?
Assists in friction protection
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?
Asymmetric, irregular borders
Assessment of a client's nails reveals Beau's lines. The nurse interprets this finding as indicating which of the following?
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?
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure
Which clinical manifestation should the nurse expect to find in a client with edema?
Decreased skin mobility
Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following?
Discrete
During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
Existence of systemic diseases that have skin manifestations
A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify which of the following as an
Fissure
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?
Impetigo
A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?
Increased thinness
A client's fingernails are noted to be very thin and concave. The nurse knows the client needs medical follow-up for further assessment of which condition?
Iron deficiency anemia
The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding?
Normal finding
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?
Oral mucosa
A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?
Pustular acne
A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do?
Reassure the mother that this is normal.
A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely?
Seborrheic keratosis
A client's history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client's skin as which of the following?
Thin
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
dermis
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)
notched border diameter great than 6 mm asymmetry
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 client's
oral mucosa.
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on body sites with heavy sun exposure.
Local redness of the skin warns of impending necrosis.
true
To assess an adult client's skin turgor, the nurse should
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.
