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.

Accepted Answer

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?

Accepted Answer

Thinning skin,with decreased attachment between the dermis and the epidermis,is at increased risk for injury in response to even minimal trauma or shearing events.If injury occurred,infection would be a possible problem.Thin skin should not cause discomfort.Poor self-image does not take priority over the risk for injury.

Question 3

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

Accepted Answer

Increased hair growth on the face and chest of a female client (hirsutism)is one manifestation of hormonal imbalance.The nurse looks for additional associated changes in fat distribution and capillary fragility (Cushing's syndrome)or clitoral enlargement and deepening of the voice (possible ovarian dysfunction).The other options are not related to this condition.

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?

Accepted Answer

Rashes limited to skin-fold areas (e.g.,on the axillae,beneath the breasts,in the groin)may reflect problems related to excessive moisture.The client needs to keep the area dry; one option is to use powder.Good hygiene is important,but the rash does not need an antibacterial soap.The other two options are not related to rashes in skin folds.

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?

Accepted Answer

Patches are larger flat areas of the skin.The information provided does not indicate a mole or the presence of erythema.

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?

Accepted Answer

Freckles,birthmarks,and age spots are caused by patches of melanin in the skin.Melanin protects against the harmful effects of sun exposure.Hyperpigmentation can occur in sun-exposed areas and can lead to skin cancer.For clients who spend time outdoors,the best protection from skin cancer is decreasing the amount of skin exposed to sunlight.

Question 7

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

Accepted Answer

The Wood's light examination consists of use of a black light and a darkened room to assist with physical examination of the skin.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?

Accepted Answer

A rash that is flat is described as macular.The other descriptions are not accurate.

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?

Accepted Answer

The dermis or dermal layer of the skin contains sensory nerves that transmit sensations of touch,pressure,temperature,pain,and itch.

Question 10

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

Accepted Answer

Certain drugs such as aspirin,warfarin,and corticosteroids can lead to easy or excessive bruising,which can result in ecchymosis.The other options would not provide information about bruising.

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?

Accepted Answer

A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade.The other techniques are not used for a suspected superficial fungal infection.

Question 12

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

Accepted Answer

The asymmetric 6-mm dark lesion,as well as the lesion with various colors,fits two of the American Cancer Society's hallmark signs for cancer according to the ABCD method.Other manifestations are variants of normal seen in various age-groups.

Question 13

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

Accepted Answer

This client has no reason to avoid going about normal activities as long as the site stays covered for a day with a dressing.Movement should not cause excessive bleeding,and general anesthesia would not have been used.

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?

Accepted Answer

Localized,decreased skin temperature and pallor indicate interference with vascular flow to the region.The nurse should assess bilateral pedal pulses to screen for vascular sufficiency.Without adequate blood flow,the client's limb could be threatened.Asking about a family history of skin problems would not take priority over assessing blood flow.Homans' sign is a screening tool for deep vein thrombosis and is often inaccurate.Skin turgor gives information about hydration status.This assessment may be needed but certainly does not take priority over assessing for blood flow.

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?

Accepted Answer

The condition,chronic paronychia,is common in people with frequent intermittent exposure to water,such as homemakers,bartenders,and laundry workers.

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?

Accepted Answer

The location of the rash suggests contact dermatitis.This condition is most often caused by contact with irritating substances such as might be found in industrial settings or associated with specific hobbies.Socioeconomic status may be related to the rash,particularly if it is associated with poor hygiene,but age and gender are not related to rashes.

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?

Accepted Answer

The ABCDE method (check for asymmetry,border irregularity,color variation,diameter,and evolving [changing] in any feature)should be used to assess lesions for signs associated with cancer.Any positive finding using this method requires the lesion to be examined by a dermatologist or a surgeon.The other options are good instructions for clients too,but this client is worried about lesions that are already present.

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?

Accepted Answer

Cyanosis can be present when impaired gas exchange occurs.In a client with dark skin,cyanosis can be seen because the palms,soles,and conjunctivae have a bluish tinge.The nurse should assess for systemic oxygenation before continuing with other assessments.

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

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.