Deck 24: Assessment of the Skin, Hair, and Nails

Question 1

A nurse assesses a client who has open lesions.Which action should the nurse take first?

A) Put on gloves.
B) Ask the client about his or her occupation.
C) Assess the client's pain.
D) Obtain vital signs.

Answer 1

Put on gloves.

Question 2

After teaching a client who expressed concern about a rash located beneath her breast,a nurse assesses the client's understanding.Which statement indicates the client has a good understanding of this condition?

A) "This rash is probably due to fluid overload."
B) "I need to wash this daily with antibacterial soap."
C) "I can use powder to keep this area dry."
D) "I will schedule a mammogram as soon as I can."

Answer 2

"I can use powder to keep this area dry."

Question 3

A nurse cares for an older adult client who has a chronic skin disorder.The client states,"I have not been to church in several weeks because of the discoloration of my skin." How should the nurse respond?

A) "I will consult the chaplain to provide you with spiritual support."
B) "You do not need to go to church; God is everywhere."
C) "Tell me more about your concerns related to your skin."
D) "Religious people are nonjudgmental and will accept you."

Answer 3

"Tell me more about your concerns related to your skin."

Question 4

While assessing a client,a nurse detects a bluish tinge to the client's palms,soles,and mucous membranes.Which action should the nurse take next?

A) Ask the client about current medications he or she is taking.
B) Use pulse oximetry to assess the client's oxygen saturation.
C) Auscultate the client's lung fields for adventitious sounds.
D) Palpate the client's bilateral radial and pedal pulses.

Question 5

A nurse assesses an older adult's skin.Which findings require immediate referral? (Select all that apply.)

A) Excessive moisture under axilla
B) Increased hair thinning
C) Increased presence of fungal toenails
D) Lesion with various colors
E) Spider veins on legs
F) Asymmetric 6-mm dark lesion on forehead

Question 6

During skin inspection of a client,a nurse observes lesions with wavy borders that are widespread across the client's chest.Which descriptors should the nurse use to document these observations?

A) Clustered and annular
B) Linear and circinate
C) Diffuse and serpiginous
D) Coalesced and circumscribed

Question 7

A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates.Which question should the nurse ask to elicit useful information about the possible condition?

A) "What do you do for a living?"
B) "Are your nails professionally manicured?"
C) "Do you have diabetes mellitus?"
D) "Have you had a recent fungal infection?"

Question 8

A nurse plans care for a client who has a wound that is not healing.Which focused assessments should the nurse complete to develop the client's plan of care? (Select all that apply.)

A) Height
B) Allergies
C) Alcohol use
D) Prealbumin laboratory results
E) Liver enzyme laboratory results

Question 9

A nurse assesses an older adult client with the skin disorder shown below:

How should the nurse document this finding?

A) Petechiae
B) Ecchymoses
C) Actinic lentigo
D) Senile angiomas

Question 10

A nurse assesses a client and identifies that the client has pallor conjunctivae.Which focused assessment should the nurse complete next?

A) Partial thromboplastin time
B) Hemoglobin and hematocrit
C) Liver enzymes
D) Basic metabolic panel

Question 11

A nurse assesses a client who has a chronic skin disorder.Which finding indicates the client is effectively coping with the disorder?

A) Clean hair and nails
B) Poor eye contact
C) Disheveled appearance
D) Drapes a scarf over the face

Question 12

While assessing a client's lower extremities,a nurse notices that one leg is pale and cooler to the touch.Which assessment should the nurse perform next?

A) Ask about a family history of skin disorders.
B) Palpate the client's pedal pulses bilaterally.
C) Check for the presence of Homans' sign.
D) Assess the client's skin for adequate skin turgor.

Question 13

A nurse teaches a client to perform total skin self-examinations on a monthly basis.Which statements should the nurse include in this client's teaching? (Select all that apply.)

A) "Look for asymmetry of shape and irregular borders."
B) "Assess for color variation within each lesion."
C) "Examine the distribution of lesions over a section of the body."
D) "Monitor for edema or swelling of tissues."
E) "Focus your assessment on skin areas that itch."

Question 14

A nurse assesses a client who has multiple areas of ecchymosis on both arms.Which question should the nurse ask first?

A) "Are you using lotion on your skin?"
B) "Do you have a family history of this?"
C) "Do your arms itch?"
D) "What medications are you taking?"

Question 15

A nurse assesses a client who has two skin lesions on his chest.Each lesion is the size of a nickel,flat,and darker in color than the client's skin.How should the nurse document these lesions?

A) Two 2-cm hyperpigmented patches
B) Two 1-inch erythematous plaques
C) Two 2-mm pigmented papules
D) Two 1-inch moles