Deck 26: Assessment of the Skin,hair,and Nails

Question 1

The nurse observes yellow-tinged sclera on a client with dark skin.Based on this observation,what is the nurse's best action?
a.
Evaluate the client further for hepatitis.
b.

Answer 1

A: The nurse's best action upon observing yellow-tinged sclera on a client with dark skin is to evaluate the client further for signs of jaundice, which can be an indication of liver dysfunction such as hepatitis. Jaundice is the yellowing of the skin and sclerae (the white part of the eyes) caused by high levels of bilirubin in the blood. This can occur due to various conditions, but hepatitis is a common cause.

The nurse should perform a comprehensive assessment, including:

1. Asking the client about other symptoms such as fatigue, abdominal pain, nausea, vomiting, fever, dark urine, or pale stools.
2. Reviewing the client's medical history for risk factors associated with liver disease, such as alcohol use, medication use, exposure to toxins, or a history of viral hepatitis.
3. Conducting a physical examination to check for additional signs of liver disease, such as hepatomegaly (enlarged liver), ascites (fluid in the abdomen), or spider angiomas (small, spider-like blood vessels visible under the skin).
4. Reviewing recent laboratory test results, if available, for liver function tests (LFTs), including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and bilirubin levels.
5. Collaborating with the healthcare team to determine if further diagnostic testing is needed, such as additional blood tests, imaging studies, or a referral to a specialist.

Prompt identification and management of the underlying cause of jaundice are important to prevent potential complications and to provide appropriate treatment.

Question 2

The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms.What is the client's priority problem?

A) Risk for injury
B) Infection
C) Poor self-image
D) Discomfort

Answer 2

Risk for injury

Question 3

The nurse observes hirsutism in a female client.What does the nurse do next?

A) Assess for deepening of the voice.
B) Assess personal hygiene habits.
C) Document the finding.
D) Prepare the client for a biopsy.

Answer 3

Assess for deepening of the voice.

Question 4

A client expresses concern about a rash located beneath her breast.What statement by the client indicates 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."

Question 5

A client has two skin lesions,each the size of a nickel,on his chest.Both lesions are flat and are a darker color than the rest of the client's skin.How does the nurse document this finding?

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

Question 6

An older client with age spots is fearful of contracting skin cancer but wants to continue his hobby of outdoor gardening.Which statement by the client indicates a good understanding of the teaching about this issue?

A) "I will avoid staying outside during the day."
B) "I can use only oil-based tanning lotion."
C) "I have to start growing plants indoors."
D) "I will wear a hat and gloves when gardening."

Question 7

A client asks the nurse if a Wood's light examination is painful.Which response by the nurse is accurate?

A) "A local anesthetic will be used to prevent pain."
B) "The pain lasts only a few seconds."
C) "Some clients feel a pressure-like sensation."
D) "The examination does not cause discomfort."

Question 8

The nurse reads in the chart that a client has a fine,macular rash on the lower extremities.The nurse inspects the client's skin,looking for lesions that can be described with which term?

A) Flat
B) Raised
C) Rough
D) Blood-filled

Question 9

A client comes to the clinic reporting pain and itching from blisters on both arms.This finding indicates an abnormality in which layer of the skin?

A) Adipose tissue
B) Dermis
C) Epidermis
D) Stratum corneum

Question 10

A client has multiple bruises on the arms.Which question provides the nurse with the most information?

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

Question 11

A client has a suspected superficial fungal infection.The nurse prepares the client for a culture by explaining the procedure.Which statement by the client indicates a correct understanding of the procedure?

A) "The doctor will shave off a small piece of the lesion."
B) "You will be performing what is called a punch biopsy."
C) "A sample is obtained by simply scraping the lesion."
D) "You'll squeeze material from the lesion to send to the laboratory."

Question 12

The nurse is assessing for skin changes in an older woman.Which findings require immediate referral?

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 13

A client had an excisional biopsy on a neck lesion.Which information does the nurse include in the discharge instructions?

A) "Stay in bed today to prevent excessive bleeding from the incision."
B) "Do not drive until you have recovered from the anesthesia."
C) "You will need to change the dressing daily for a week."
D) "Keep the dressing on until tomorrow, then you may remove it."

Question 14

On assessing a client's lower extremities,the nurse notices that one leg is pale and cooler to the touch.Which assessment does 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 15

A client is admitted with inflamed soft tissue folds around his nail plates.Which question by the nurse elicits the most useful information about the possible condition?

A) "What do you do for a living?"
B) "Do you keep your nails manicured?"
C) "Do you have diabetes?"
D) "Have you had any fungal nail infections?"

Question 16

A client is seen in the clinic for a persistent hand rash.When taking the client's history,the nurse places priority on obtaining information related to which topic?

A) Age
B) Gender
C) Occupation and hobbies
D) Socioeconomic status

Question 17

An older client expresses concern about developing new "age spots." Which instruction is most important for the nurse to provide to the client?

A) "Limit the time you spend in the sun."
B) "Monitor for signs of infection."
C) "Monitor spots for color change."
D) "Use skin creams to prevent drying."

Question 18

A client has a bluish tinge to the palms,soles,and conjunctivae.Based on these assessment data,what does the nurse do next?

A) Take a medication history.
B) Assess pulse oximetry.
C) Assess the client's personal hygiene.
D) Palpate the soles and palms.