PrepU - Assessment: Skin, Hair, Nails
vesicle
A client has a circumscribed, elevated, palpable mass containing serous fluid on the forearm. Which diagram should the nurse use to explain this mass to the client?
osteomyelitis
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?
Skin warm and dry to the touch
A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?
Inspect the area
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
high
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?
patchy, thin hair
A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?
yeast infection
A nurse performs a focused assessment on a client who has noticed changes in their nail beds. The nurse observes white color and separation of the nail plate from the nail bed. The nurse determines that these signs and symptoms indicate which of the following conditions?
Uticaria or hives
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?
vellus
Short, pale, and fine hair that is present over much of the body is termed
overall amount of sun exposure.
Squamous cell carcinoma is associated with
Stage II
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
The client may have been abused.
The nurse is admitting a 79-year-old man for outpatient surgery. The client 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?
ashen
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
acne
Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?
fainting
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
Wood's light (answer)
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Palmar surfaces
When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:
The client's perception affects the approach and effectiveness in treating the skin condition
Why is it important for the nurse to ask the client what they think caused a skin condition?
bacterial infection of nail
cause green, black, or brown discoloration
peripheral cyanosis
common condition that typically occurs when child is slightly cold and adjusting peripheral circulation to keep the core warm; no further workup needed if no other problems present; if lips or central locations involved, additional considerations
central cyanosis
results from a cardiopulmonary problem
Wood's light (defined)
ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection.
areola of the breast.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
Carotene
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
pustular acne
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?
oral mucosa
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
a great degree of cyanosis.
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
dry and rough
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?
Have a nurse who is the same sex as the client examine him
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution
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?
notched border, diameter greater than 6 mm, asymmetry
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)
Under the breast
Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?
dermis
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Synthesis of vitamin D
Which of the following is an important function of the skin?
Pinch the skin over the clavicle and observe its return to the original shape
Which technique should the nurse use to properly assess a client's skin turgor?
macules (answer)
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
a recent illness
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
impetigo (defined)
most often a child scratches a bug bite or other lesion that becomes infection with bacteria; bacteria then produce honey colored exudate.
symptoms of stress
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:
intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
avoiding sun exposure
Recommended protective measures to avoid skin cancer include which of the following?
The cyanosis may be a result of a prolonged period of exposure to the cold.
The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?
Distribution
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
yeast infection of nail
cause white color and separation of the nail plate from the nail bed
fungal infection of nail
cause yellow, thick, crumbling nails
Hypothyroidism
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
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?
tinea corporis
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?
Seborrheic keratosis
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?
stage III
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?
Asymmetrical shape
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?
impetigo (answer)
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?
Reassure the mother that this is normal.
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?
Document the findings in the client's record as normal
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?
Broken with the presence of a blister
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
67-year-old White female
A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?
hypoxia
A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?
Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed
A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.
Asymmetrical, change in size, itching, bleeding of a mole
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.
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
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.
Dermis
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?
document findings
A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take?
"Do you feel anxious at times?"
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?
fissures
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
Risk for Impaired Skin Integrity
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?
underarms
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?