Chapter 26: Assessment of the Skin, Hair, and Nails Nursing School Test Banks

Chapter 26: Assessment of the Skin, Hair, and Nails

Test Bank

MULTIPLE CHOICE

1. 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 clients priority problem?

a.

Risk for injury

b.

Infection

c.

Poor self-image

d.

Discomfort

ANS: A

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Planning)

2. 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?

a.

The doctor will shave off a small piece of the lesion.

b.

You will be performing what is called a punch biopsy.

c.

A sample is obtained by simply scraping the lesion.

d.

Youll squeeze material from the lesion to send to the laboratory.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning

3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation, what is the nurses best action?

a.

Evaluate the client further for hepatitis.

b.

Examine the soles of the clients feet.

c.

Inspect the clients oral mucosa.

d.

Place the client in contact isolation.

ANS: C

The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits that show a yellow hue. Before considering hepatitis, the nurse must do a more thorough assessment. The soles of the feet may appear yellow simply from calluses, so this is not the best place to assess. No need to isolate the client has been identified.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)

4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data, what does the nurse do next?

a.

Take a medication history.

b.

Assess pulse oximetry.

c.

Assess the clients personal hygiene.

d.

Palpate the soles and palms.

ANS: B

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

5. 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?

a.

I will avoid staying outside during the day.

b.

I can use only oil-based tanning lotion.

c.

I have to start growing plants indoors.

d.

I will wear a hat and gloves when gardening.

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

6. An older client expresses concern about developing new age spots. Which instruction is most important for the nurse to provide to the client?

a.

Limit the time you spend in the sun.

b.

Monitor for signs of infection.

c.

Monitor spots for color change.

d.

Use skin creams to prevent drying.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

7. A client is seen in the clinic for a persistent hand rash. When taking the clients history, the nurse places priority on obtaining information related to which topic?

a.

Age

b.

Gender

c.

Occupation and hobbies

d.

Socioeconomic status

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

8. 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?

a.

What do you do for a living?

b.

Do you keep your nails manicured?

c.

Do you have diabetes?

d.

Have you had any fungal nail infections?

ANS: A

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

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

a.

Are you using lotion on your skin?

b.

Do you have a family history of this?

c.

Do your arms itch?

d.

What medication are you taking?

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

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

a.

Stay in bed today to prevent excessive bleeding from the incision.

b.

Do not drive until you have recovered from the anesthesia.

c.

You will need to change the dressing daily for a week.

d.

Keep the dressing on until tomorrow, then you may remove it.

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

11. A client asks the nurse if a Woods light examination is painful. Which response by the nurse is accurate?

a.

A local anesthetic will be used to prevent pain.

b.

The pain lasts only a few seconds.

c.

Some clients feel a pressure-like sensation.

d.

The examination does not cause discomfort.

ANS: D

The Woods 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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 468

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Teaching/Learning

12. A client expresses concern about a rash located beneath her breast. What statement by the client indicates 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.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

13. 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?

a.

Adipose tissue

b.

Dermis

c.

Epidermis

d.

Stratum corneum

ANS: B

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

DIF: Cognitive Level: Knowledge/Remembering REF: p. 453

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

14. 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 clients skin. How does the nurse document this finding?

a.

Two 2-cm hyperpigmented patches

b.

Two 1-inch erythematous plaques

c.

Two 2-mm pigmented papules

d.

Two 1-inch moles

ANS: A

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

DIF: Cognitive Level: Comprehension/Understanding REF: p. 460

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse reads in the chart that a client has a fine, macular rash on the lower extremities. The nurse inspects the clients skin, looking for lesions that can be described with which term?

a.

Flat

b.

Raised

c.

Rough

d.

Blood-filled

ANS: A

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

DIF: Cognitive Level: Knowledge/Remembering REF: p. 463

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

16. On assessing a clients lower extremities, the nurse notices that one leg is pale and cooler to the touch. Which assessment does 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.

ANS: B

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 clients 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

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

a.

Assess for deepening of the voice.

b.

Assess personal hygiene habits.

c.

Document the finding.

d.

Prepare the client for a biopsy.

ANS: A

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 (Cushings syndrome) or clitoral enlargement and deepening of the voice (possible ovarian dysfunction). The other options are not related to this condition.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. The nurse is assessing for skin changes in an older woman. 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

ANS: D, F

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

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