WorksheetsChapter 14: Assessing Skin, Hair, and Nails (HA)
Total questions: 56
Worksheet time: 30mins
The nurse is assessing a dark-skinned 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
a great degree of cyanosis.
a mild degree of cyanosis.
lupus erythematosus.
hyperthyroidism.
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
Diabetes mellitus
Hypothyroidism
Crohns disease
Cushing disease
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area
Ask further questions
Document the statement
Move on to next body system
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 linear cracks in the skin on both feet. The nurse should document the presence of
ulcers.
erosion.
scales.
fissures.
A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
Assisting the client to put on a gown.The nurse preparing to conduct an integumentary assessment will include which interventions when preparing the client for this examination? (Select all that apply.)
Assisting the client to put on a gown.
Providing adequate drapes.
Using the mnemonic OLDCART as a guide.
Wearing gloves when palpating lesions.
Using cotton balls to assess for sensation.
The nurse assesses a bed-bound older adult client in the client's home. While assessing the client’s buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client’s pressure ulcer as
stage I.
stage II.
stage III.
stage IV.
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Unbroken but red in color
Ulceration resembling a crater
Exposure of subcutaneous tissue and muscle
Broken with the presence of a blister
The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?
Assists in keeping the skin intact
Assists in friction protection
Assists in protection from infection
Assists in keeping skin dry
The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?
a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution
a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution
a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution
a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter greater than 6 mm; e = evolution
A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?
Nodule
Papule
Vesicle
Macule
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
Oxyhemoglobin
Deoxyhemoglobin
Carotene
Melanin
A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?
Around the mouth and lips
Chest and abdomen
Fingers and toes
Nose and earlobes
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Keloid formation at the site of an old incision
Facial acne
Facial lesions associated with herpes simplex
Psoriasis
A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client’s risk for skin breakdown?
high
mild
moderate
negligible
As a pediatric nurse, it is important to assess each child for bruising. What might be indicated by ecchymoses in various areas of the body on a toddler or preschool-aged child? Select all that apply.
Osteomyelitis
Hematologic problem
Certain medications
Vitamin B deficiency
Coagulopathy
Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?
Anterior chest
Upper abdomen
On the neck
Under the breast
The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?
The client may have been abused.
The client is elderly.
The client may have peripheral vascular disease.
The client may have a cognitive deficit.
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
Insect bites
Urticaria or hives
Psoriasis
Purpura
A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?
Assess the client for changes in sensation due to vascular problems
Monitor the client for additional findings of cystic fibrosis
Suggest that the client use antiperspirant products
Document the findings in the client's record as normal
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
stage I.
stage II.
stage III.
stage IV.
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
stage I.
stage II.
stage III.
stage IV.
To assess for anemia in a dark-skinned client, the nurse should observe the client’s skin for a color that appears
greenish.
ashen.
bluish.
olive
When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
palms of the hands
face
soles of the feet
underarms
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
fainting
vomiting
diarrhea
diaphoresis
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
The client has chronic hypoxia
The client has melanoma
The client has COPD
The client has asthma
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?
Osteopenia
Osteoporosis
Osteoarthritis
Osteomyelitis
The terms “generalized,” “exposed surfaces,” “upper arm,” and “skin folds” are used to describe which major characteristic of skin lesions?
Type
Color
Distribution
Arrangement
A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?
Linear
Annular
Clustered
Discrete
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
Allow the client to pray before the examination
Let the client remained fully dressed for the examination
Have a nurse who is the same sex as the client examine him
Avoid asking any questions regarding the client's lifestyle
The nurse is using the mnemonic ABCDE to assess a client’s mole. What should the nurse document for the C?
color
category
consistency
characteristics
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
basal cell carcinoma.
actinic keratoses.
squamous cell carcinoma.
malignant melanoma.
Parents bring a child to the clinic and report a “rash” on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Seborrhea
Contact dermatitis
Eczema
Psoriasis
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
Multiple nevi
Tinea versicolor
Herpes simplex
Tinea corporis
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:
symptoms of stress.
recent radiation therapy.
pigmentation irregularities.
allergies to certain foods.
Short, pale, and fine hair that is present over much of the body is termed
vellus
dermal
lanugo
terminal
When inspecting the hair, what would the nurse note? (Select all that apply.)
Color
Condition of hair shaft
Length of hair
Hair breakage of more than 6 hairs
Hair shafts that are shiny
An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.
Evaluate the client's outcomes
Modify nursing interventions
Document the findings
Keep to the established care plan
Notify the physician
An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.
Evaluate the client's outcomes
Modify nursing interventions
Document the findings
Keep to the established care plan
Notify the physician
An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.
Evaluate the client's outcomes
Modify nursing interventions
Document the findings
Keep to the established care plan
Notify the physician
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Sunlight
Artificial light
Wood's light
Flashlight
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small “pits” in the nails. What would account for these findings?
Eczema
Pityriasis rosea
Psoriasis
Tinea infection
Hair follicles, sebaceous glands, and sweat glands originate from the
epidermis
eccrine glands
keratinized tissue
dermis
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure
Knowing signs of skin cancer
Performing monthly skin self-examinations
Seeking biannual examination by a clinician after age 40 years
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.
Largest organ of the body
Involved in digestion of food
Aids in maintaining body temperature
Protects against damage to the body from sunlight
Helps make vitamin D in the body
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.
pressure that impairs capillary blood flow to the skin
friction created by dragging the skin against bedlinen
shearing that occurs when sliding down in bed
moisture being allowed to accumulate on the skin
restlessly changing position frequently
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal
Papule
Pustule
Erosion
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
nodules
bullae
vesicles
wheals
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
chemotherapy.
radiation.
a recent illness.
steroid therapy.
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Keloid formation at the site of an old incision
Facial acne
Facial lesions associated with herpes simplex
Psoriasis
A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?
Transverse white lines in the nails
Beau's lines
White spots, or leukonychia, on the nail surfaces
Small pits in the surfaces of the nails
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
nail beds.
oral mucosa.
sclera
palms
A client with a zosteriform rash has a rash that
has lesions distributed over a large body area
appears with a single lesion in close proximity to a larger lesion, as if “orbiting” the larger lesion
is distributed along a dermatome
is distributed equally on both sides of the body
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
melanoma skin cancers are the most common type of cancers.
African Americans are the least susceptible to skin cancers.
usually there are precursor lesions for basal cell carcinomas.
squamous cell carcinomas are most common on body sites with heavy sun exposure.
Connecting the skin to underlying structures is/are the
papillae
sebaceous glands.
dermis layer.
subcutaneous tissue.
The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?
Lower the head of bed and pull the client up with both arms.
Place the client in Trendelenburg so the client can slide up in bed.
Call for help and use the draw sheet to move the client.
Push the client toward the head of the bed to prevent back injury.
