Deck 11: Skin, Hair Nails

Question 1

The nurse is assessing a client's skin and notes that the color of the skin,nails,and the client's mucous membranes are very light.Which of the following descriptions would the nurse use when documenting this finding?
1)Cyanosis
2)Pallor
3)Erythema
4)Jaundice

Answer 1

2

Question 2

The nurse is conducting a focused interview on the client's integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders.Which of the following questions by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?
1)"How much time do you spend outdoors?"
2)"How do you care for your skin?"
3)"Do you have any tattoos or body piercings?"
4)"Have you noticed any drainage from your skin?"

Answer 2

4

Question 3

The nurse is assessing the skin of a teenage male client and notes the presence of a musky odor.The client states that this is embarrassing for him and that he showers daily.Which of the following actions should the nurse take in this situation?
1)Reassure the teen that this is normal.
2)Notify the client's healthcare provider.
3)Obtain a dietary referral.
4)Educate the client regarding the importance of increased water intake.

Answer 3

1

Question 4

The nurse is assessing a client with liver disease and notes that the skin,mucous membranes,and sclerae are yellowish in color.The nurse would correctly document this finding as which of the following?
1)Uremia
2)Cyanosis
3)Jaundice
4)Carotenemia

Question 5

The nurse is performing a skin assessment on a client and notes an oval-shaped,elevated,fluid-filled mass that is approximately 1.5 centimeter in size.The nurse would correctly document this finding as which of the following?
1)Vesicle
2)Bulla
3)Papule
4)Tumor

Question 6

The nurse is admitting a newly admitted client and notes skin vitiligo,which is highly visible even from a distance.The client asks the nurse to place a "No Visitors" sign on the door the patient's room.The client states,"I hate the way my skin looks.Some people just stare at me." Which of the following nursing diagnoses should be incorporated into the client's plan of care?
1)Defensive coping
2)Risk for loneliness
3)Deficient knowledge
4)Disturbed body image

Question 7

The student nurse assessed the client's skin.The student nurse documented "+1 edema right lower leg." The experienced nurse expects to find which of the following based on the student nurse's documentation?
1)The presence of slight pitting,no obvious distortion
2)Deep pitting,obvious distortion
3)Pitting is obvious,extremities are swollen
4)Moderate amount of edema

Question 8

The nurse is assessing a female client and notes facial hirsutism.The client asks the nurse,"Why did this happen to me?" Which of the following statements is the nurse's best response?
1)"Your diet is not nutritionally balanced."
2)"You may have some hormone imbalances."
3)"Usually,there is not a known cause for this condition."
4)"You need to take vitamins."

Question 9

The nurse is preparing to assess the client's skin,hair,and nails.Which of the following techniques will the nurse use initially during this assessment?
1)Percussion
2)Palpation
3)Auscultation
4)Inspection

Question 10

The client visits the outpatient clinic.During the assessment of the client's skin,the nurse notes the presence of several abdominal lesions that appear in distinct clusters.The nurse would document these lesions in which of the following ways?
1)Grouped
2)Annular
3)Discrete
4)Confluent

Question 11

The nurse is completing a focused interview to assess the skin,hair,and nails of a pregnant client.Which of the following questions would be most important for the nurse to include in the interview?
1)"Do you use any skin creams?"
2)"Do you try to avoid exposure to the sun?"
3)"Have you lost any hair during your pregnancy?"
4)"Have you had any nail changes?"

Question 12

The nurse has assessed the client's skin.The nurse is preparing to document the appearance of herpetic lesions found over a client's nose and mouth region.The healthcare provider diagnosed the client with herpes simplex.Which of the following are common words that are used to describe these types of lesions?
1)Vesicular
2)Pustular
3)Pruritic
4)Ulcerated
5)Crusty

Question 13

During the assessment of a client's integumentary status the nurse notes "vitiligo present bilateral hands." This documentation indicates which of the following information?
1)Nodules with ulcerations
2)Dark,asymmetrical colored patches
3)Grouped vesicles
4)Abnormal loss of melanin in patches

Question 14

The adult client is visiting the outpatient clinic.The client states,"I have sores in my mouth and on my lips." The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek.The client states that the lesions do not itch.These findings are most consistent with the development of which of the following conditions?
1)Chickenpox
2)Contact dermatitis
3)Herpes simplex
4)Psoriasis

Question 15

The nurse is caring for a client complaining of a painful,hot area located on the client's leg.Erythema and edema are present in the localized area.Which of the following actions should the nurse perform next?
1)Palpate the area.
2)Place a heating pad on the area.
3)Notify the healthcare provider.
4)Place client on bed rest.

Question 16

The nurse is performing a skin assessment on a client and notes a round,elevated,fluid-filled mass approximately 0.4 cm in size.The nurse would correctly document this finding as which of the following?
1)Vesicle
2)Macule
3)Papule
4)Tumor

Question 17

The nurse has performed a focused interview with the client and is preparing to perform a skin assessment while the student nurse observes.The student nurse asks,"Where exactly is the stratum basale located?" Identify the stratum basale in the following figure by placing an arrow pointing toward this area.[Please insert figure 11-1 from D'Amico 2nd edition: Skin structure,3-dimensional view of skin….Remove all labels]

Question 18

The nurse is caring for a client who has smoked for many years and documents that "clubbing is present." Which of the following techniques is the best way for the nurse to determine the presence of clubbing?
1)Place two thumbs touching side-by-side.
2)Place two of the same fingers from each hand together.
3)Place two index fingers together tip-to-tip.
4)Place the hands out straight with the palm sides down.

Question 19

The nurse is assessing the client's nail.Identify the lunula by drawing an arrow pointing toward this area on the following figure.

Question 20

The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia.Which of the following findings would be expected with this diagnosis?
1)Dark red nails
2)Horizontal white bands
3)Pale nail beds
4)Spoon-shaped nails

Question 21

The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020.Which of the following are specifically related to these objectives?
1)African American females often require information regarding gentle hair and scalp care.
2)Infants have difficulty regulating their own body temperatures.
3)Older clients have increased sweat gland activity.
4)Clients with diabetes mellitus have an increased risk for skin breakdown.
5)Clients should monitor their moles for any changes,regardless of their age.

Question 22

During the assessment of an elderly client's skin,the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client's hands.The client states,"I've been getting more of these big freckles as I get older." The nurse realizes this finding is due to:
1)Senile lentigines
2)Cherry angiomas
3)Cutaneous tags
4)Cutaneous horns

Question 23

The nurse is planning to assess an African American's integumentary status.Which of the following statements by the client is most consistent with the presence of cyanosis?
1)"The whites of my eyes don't look as white anymore;they have a little bit of a yellow cast to them."
2)"My nails look a little bit bluish."
3)"My nails are bright red."
4)"My palms and the inside of my mouth look really pale."

Question 24

The nurse received a phone call from a mother who was discharged with her newborn several days ago.The mother completed the infant care teaching prior to discharge.The nurse would determine that the teaching had been effective if the mother reported which of the following?
1)Tiny,white facial bumps
2)Yellow skin and mucous membrane color
3)Irregular red patches on the back of the neck
4)Dark spots on the sacral area

Question 25

The nurse is caring for a client with dark skin and needs to assess the skin for jaundice.Which of the following actions would be appropriate for the nurse in this situation?
1)Use a bright lamp and a magnifying glass.
2)Document "unable to assess" for skin changes.
3)Assess the skin the same way you would inspect a client with lighter skin.
4)Inspect the lips,oral mucosa,sclera,conjunctivae,and palms.

Question 26

The nurse is performing a skin assessment on an African American client and notes an elevated,irregular band of jagged tissue on the client's left arm.The client states,"I had a burn here a long time ago,but it seemed to keep on getting bigger." The nurse would correctly document this finding in which of the following ways?
1)Ulcer
2)Keloid
3)Fissure
4)Scar

Question 27

The nurse is caring for a client who had abdominal surgery several months ago.The client has verbalized concern that the scar from the surgery is purplish in color.Which of the following statements is the nurse's best response?
1)"Having a scar is unavoidable."
2)"The color is normal and will fade with time."
3)"You can have plastic surgery to remove the scar later."
4)"You should be glad your surgery was a success."

Question 28

The nurse is assessing the skin of a newborn infant and notes a bright red,raised lesion on the lateral aspect of the thigh.The lesion is 4.5 centimeters in diameter.When light pressure is applied to the lesion,the site does not blanch.The mother expresses concern about the appearance of this site,and asks the nurse if it should be removed.Which of the following would be the best response for the nurse in this situation?
1)"Your pediatrician can make a surgical referral for you."
2)"It really is not that noticeable."
3)"You should be happy that your baby is healthy overall."
4)"These types of lesions usually disappear by the time a child turns 10 years old."

Question 29

The nurse is performing an assessment of the client's skin when the nurse notes that the client has become pale and diaphoretic.The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76,heart rate is 88 beats per minute,and respiratory rate is 18 breaths per minute.Which of the following actions should the nurse take first?
1)The nurse immediately raises the client's head of bed.
2)The nurse asks the client,"Are you feeling anxious during this assessment?"
3)The nurse immediately notifies the client's healthcare provider.
4)The nurse provides the client with ½ cup of orange juice.