Chapter 20: Med Surg- Assessment of the Skin, Hair and Nails

While assessing a client, a nurse detects a bluish tinge to the clients 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 clients oxygen saturation.

c. Auscultate the clients lung fields for adventitious sounds.

d. Palpate the clients bilateral radial and pedal pulses.

b. Use pulse oximetry to assess the clients oxygen saturation.

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?

a. What do you do for a living?

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?

d. What medications are you taking?

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients 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.

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

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 clients 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

a. Two 2-cm hyperpigmented patches

While assessing a clients 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 clients pedal pulses bilaterally.

c. Check for the presence of Homans sign.

d. Assess the clients skin for adequate skin turgor.

b. Palpate the clients pedal pulses bilaterally.

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.

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

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 clients pain.

d. Obtain vital signs.

a. Put on gloves.

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

a. Clean hair and nails

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

b. Hemoglobin and hematocrit

During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients 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

b. Linear and circinate

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

a. Petechiae

1. A nurse assesses an older adults 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

D. F

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 clients plan of care? (Select all that apply.)

a. Height

b. Allergies

c. Alcohol use

d. Prealbumin laboratory results

e. Liver enzyme laboratory results

A, C, D

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients 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.

A, B