PrepU skin hair nails
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
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.
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what? Oxyhemoglobin Deoxyhemoglobin Carotene Melanin
Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? Inspect the area Ask further questions Document the statement Move on to next body system
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.
Why is it important for the nurse to ask the client what they think caused a skin condition? The client's perception affects the approach and effectiveness in treating the skin condition The nurse can alleviate the client's fears about what caused the skin condition Doing so allows the client to decide what treatment is the best course of action Doing so encourages the client to use home remedies to reduce medical cost
The client's perception of the cause, reason for onset, type of treatment needed, and fears related to a skin problem or any illness will affect the approach and effectiveness in treating the client's skin condition. The nurse would not ask the client what they thought caused the skin condition to alleviate the client's fear about what caused the skin condition. The nurse would not ask to include the client in deciding what treatment is best or to encourage the client to use home remedies.
Hair follicles, sebaceous glands, and sweat glands originate from the epidermis. eccrine glands. keratinized tissue. 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.
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 Papule Wheal Cyst
The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy
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.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? Psoriasis, fungal infections, trauma Vitiligo, hirsutism, vitamin deficiency Eczema, melanoma, herpes zoster Alopecia, dermatitis, chemotherapy
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.
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
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.
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.
Older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.
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? Around the mouth and lips Chest and abdomen Fingers and toes Nose and earlobes
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.
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 is characterized by reddish-pink lesions covered with silvery scales. It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia? Clubbing Spooning Beau's lines Paronychia
Spoon nails are indicative of iron deficiency anemia. Clubbing may not be present because it is evident in people who have oxygen deficiency. Beau's lines occur after acute illness and eventually grow out. Paronychia is an infection of the nail bed and is not a characteristic feature of iron deficiency anemia.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the areola of the breast. entire skin surface. soles of the feet. adipose tissue.
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.
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions? Type Colour Distribution Arrangement
The given terms denote anatomic location, or distribution, of skin lesions over the body.
When assessing a client's terminal hair distribution, the nurse inspects all the following areas except: Limbs Vertex Eyebrows Palmar surfaces
The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer
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 female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply. Disturbed Body Image Ineffective Individual Coping Anxiety Impaired Skin Integrity Risk for Infection
This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection.
Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely? An enlarged lymph node A sebaceous cyst An actinic keratosis A malignant lesion
This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node and these do not usually drain to the skin.
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? Eczema Pityriasis rosea Psoriasis Tinea infection
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.
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? Insect bites Urticaria or hives Psoriasis Purpura
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.