Question 1

The pediatric nurse conducts a follow-up phone call for a mother who was discharged with her newborn several days ago. The mother tells the nurse that she thinks her newborn is jaundice. Which question by the nurse will help to support this mother's statement?

Accepted Answer

Yellowing of the skin and mucous membranes is a common sign of jaundice.

Question 2

The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. Which term is most appropriate for the nurse to use to describe this condition when documenting in the medical record?

Accepted Answer

Jaundice is the term used to describe the yellowish discoloration of the skin, mucous membranes, and sclerae that is associated with liver disease. Uremia refers to the accumulation of waste products in the blood due to kidney dysfunction. Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to decreased oxygenation. Carotenemia refers to a yellowish discoloration of the skin due to an excessive intake of carotenoids, such as beta-carotene.

Question 3

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 question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?

Accepted Answer

A,B,C,E

Question 4

The nurse is caring for a client who has smoked for many years and documents that "clubbing is present." Which technique is the best way for the nurse to determine the presence of clubbing?

Accepted Answer

The answer of The nurse is caring for a client...

Question 5

The nurse is assessing a client in an outpatient clinical and notes the notes the presence of several abdominal lesions that appear in distinct clusters. When documenting this finding, which term will the nurse use?

Accepted Answer

Grouped lesions are those that cluster together in a specific area, which matches the description given.

Question 6

The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which question would be most important for the nurse to include in the interview?

Accepted Answer

The answer of The nurse is completing a focused interview...

Question 7

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 action should the nurse perform next?

Accepted Answer

The presence of erythema and edema in a localized area could indicate an infection or inflammation. The nurse should notify the healthcare provider to assess and treat the client's condition appropriately. Palpating the area may spread the infection if present, and heating the area may exacerbate the inflammation. Bed rest may be necessary based on the healthcare provider's assessment, but this is not the priority action.

Question 8

The adult client is being assessed at an outpatient clinic and 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. Based on this assessment data, which condition is this client likely experiencing?

Accepted Answer

The presence of crusted lesions on the lips and inside the mouth along the cheek is a characteristic manifestation of herpes simplex. Chickenpox presents with small, itchy, fluid-filled blisters, contact dermatitis presents with red, itchy rash that may blister, and psoriasis presents with scaly, red patches on the skin. The fact that the client reports that the lesions do not itch supports a diagnosis of herpes simplex, as this condition typically causes painful sores rather than itchy ones like contact dermatitis or chickenpox.

Question 9

The nurse is assessing a client's skin and notes a very light color on the skin, nails, and the client's mucous membranes. Which descriptions would the nurse use when documenting this finding?

Accepted Answer

Pallor is a very light color on the skin, nails, and mucous membranes, which can indicate anemia or a decrease in blood flow. Cyanosis refers to blue or purple discoloration due to inadequate oxygenation, erythema refers to redness due to inflammation, and jaundice refers to a yellow color caused by buildup of bilirubin in the blood.

Question 10

The nurse completes a skin assessment for a client and is preparing to document the appearance of herpetic lesions found over a client's nose and mouth region. Which terms can the nurse use when documenting the skin assessment for this client in the medical record?

Accepted Answer

The answer of The nurse completes a skin assessment for...

Question 11

The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, "Why did this happen to me?" Which statement is the nurse's best response?

Accepted Answer

Facial hirsutism, which is the growth of excess hair on the face, is often caused by hormone imbalances such as an increase in androgen levels. It is important for the client to speak to their healthcare provider about possible causes and treatment options. There is no evidence to support that diet or vitamin deficiencies cause facial hirsutism.

Question 12

The nurse is reviewing documentation for a client from the previous shift. The documentation states, "+1 edema right lower leg." Based on this data, what does the nurse expect when assessing this client?

Accepted Answer

"+1" edema indicates slight pitting, no obvious distortion.

Question 13

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. Which term is the most appropriate for the nurse to use when documenting this finding in the medical record?

Accepted Answer

A round, elevated, fluid-filled mass is characteristic of a vesicle, which is a type of primary skin lesion. A macule is a flat, non-elevated area of skin discoloration, while a papule is a small, solid, elevated mass. A tumor is a general term for any abnormal growth or swelling, which may or may not be fluid-filled. Therefore, choice A (Vesicle) is the most appropriate term to use in this scenario.

Question 14

During the assessment of a client's integumentary status the nurse notes "vitiligo present bilateral hands." Which analysis of this information is the most appropriate by the nurse?

Accepted Answer

Vitiligo is an autoimmune condition characterized by the abnormal loss of melanin in patches, leading to depigmented or white patches on the skin. Nodules with ulcerations suggest a different condition such as skin cancer or scleroderma. Dark, asymmetrical colored patches may suggest melanoma. Grouped vesicles may suggest herpes simplex or herpes zoster infection.

Question 15

The nurse is assessing the skin of an adolescent client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which action should the nurse take in this situation?

Accepted Answer

The presence of a musky odor in an adolescent is often due to hormonal changes associated with puberty, which can increase sweat production and alter body odor. Reassuring the teen that this is a normal part of development is appropriate.

Question 16

The nurse is inspecting the fingernails of a client who is diagnosed with polycythemia. Which assessment data would be expected for this client?

Accepted Answer

Dark red nails are expected in clients with polycythemia because of increased red blood cell production.

Question 17

The nurse is conducting an admission assessment for a 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 client states, "I hate the way my skin looks. Some people just stare at me." Which nursing diagnosis should be incorporated into the client's plan of care?

Accepted Answer

The client's statement about hating the way their skin looks and being self-conscious about others staring at them suggests a Disturbed Body Image nursing diagnosis. The client's request for a "No Visitors" sign may also be indicative of this diagnosis.

Question 18

The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size. Which term will the nurse use when documenting this assessment data?

Accepted Answer

An oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size is characteristic of a bulla. A vesicle is smaller, less than 1 centimeter in size, and contains clear fluid. A papule is a solid, elevated, and rounded lesion that is less than 1 centimeter in size. A tumor, on the other hand, is a larger mass that may be solid or fluid-filled and is typically greater than 2 centimeters in size.

Question 19

The nurse is preparing to assess the client's skin, hair, and nails. Which technique will the nurse use initially during this assessment?

Accepted Answer

Inspection is the appropriate technique to initially assess the skin, hair, and nails. Inspection involves visual examination and observation of the area of interest. Percussion, palpation, and auscultation are all techniques used for other types of assessments, such as assessment of the abdomen or lungs.

Question 20

The nurse preparing to perform a skin assessment while a student nurse observes. The student nurse asks, "Where exactly is the stratum basale located?" Which location will the nurse use to correctly identify this for the student nurse?

Accepted Answer

The stratum basale is the deepest layer of the epidermis and it is located at the base of the epidermis, which is represented by option A in the diagram.

Quiz 13: Skin, Hair, Nails