Chapter 14 Assessing Hair, Skin, and Nails

Chapter 14 Assessing Hair, Skin, and Nails Connecting the skin to the underlying structures is/are the D. Subcutaneous tissue The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin D. D The only layer of the skin that undergoes cell division is the A. innermost layer of epidermis Skin color depends on melanin and carotene contained in the skin and the A. genetics B. volume of circulating blood C. Lymph vessels D. Vascularity of apocrine glands B. volume of circulating blood Hair follicles, sebaceous glands, and sweat glands originate from the A. epidermis B. eccrine glands C. keratinized tissue D. dermis D. dermis Apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the ____ A. areola of the breast B. entire skin surface C. soles of the feet D. adipose tisse A. areola of the breast Short, pale, and fine hair that is present over much of the body is termed A. vellus B. dermal C. lanugo D. terminal A. vellus Primary function of hair in the nose and eyelashes is to serve as B. filter for dust The nails, located on the distal phalanges of the fingers and toes, are composed of C. keratinized epidermal cells Squamous cell carcinoma is associated with A. overall amount of sun exposure 1. An adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the "result of an accident." The nurse suspects that the client may be experiencing Ans: Domestic abuse 2. An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for Ans: Symptoms of stress 3. The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that Ans: Squamous cell carcinomas are most common on body sites with heavy sun exposure 4. The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to Ans: Chronic discoid lupus erythematosus 5. A 20 year old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of Ans: Hypothyroidism 6. A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially Ans: Malignant melanoma 7. A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate Ans: Fluid intake 8. An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's Ans: Oral mucosa 9. To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears Ans: ashen 10. The nurse is assessing a dark-skinned client client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of Ans: A great degree of cyanosis 11. A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's Abs: Sclera 12. 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 Ans: Are caused by aging of the skin in older adults 13. While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is Ans: Blue 14. The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as Ans: Stage II 15. To assess an adult client's skin turgor, the nurse should Ans: Use two fingers to pinch the skin under the clavicle 16. While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had Ans: A recent illness 17. While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of Ans: Hypoxia 18. While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of Ans: Macules 19. While assessing an adult client, the nurse observes an elevated palpable, solid mass with a circumscribed border that measures 1cm. The nurse documents this as a Ans: Plaque 20. The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's Ans: Vesicles 21. An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has a linear cracks in the skin on booth feet. The nurse should document the presence of Ans: Fissures 22. An African American female client visits the clinic. She tells the nurse that she has had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear. The nurse should document a Ans: Keloid 23. A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per weeks. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is Ans: Risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions lichenification thickening of the skin characterized by accentuated skin marking--thickened, roughened skin urticaria hives, prurtic wheals, often transient and allergic in oriigin papule solid, elevated, circumscribed, superficial lesion; 1cm or less in diameter wheal elevated, solid, transient lesion; often irregularly shaped; an edematous--localized edema (ex. insect bite) keloid hypertrophic scar tissue; prevalent in nonwhite races nevus congenital pigmented area on skin, mole or birthmark petechiae tiny, flat, purple or red spots on the surface of the skin resulting from minute hemorrhaging--red or purple macules annular describes a lesion that forms a ring around a clear center of normal skin induration hardening of the skin, usually caused by edema bulla an elevated, circumscrbed, fluid-filled lesion that is greater than 1cm in diameter