ch65.doc

Chapter 65

[Osborn] chapter 65

Learning Outcomes [Number and Title ]

Learning Outcome 1Discuss the structure and function of the skin.

Learning Outcome 2Obtain a health history relative to assessment of the skin, hair, and nails.

Learning Outcome 3Collect subjective and objective data relative to assessment of the skin, hair, and nails.

Learning Outcome 4Utilize correct techniques of physical exam when assessing the skin, hair, and nails.

Learning Outcome 5Distinguish between normal and abnormal assessment findings in the skin, hair, and nails.

Learning Outcome 6Describe skin lesions by morphologic classification.

Learning Outcome 7Identify biologic and cultural variations in assessment of the skin.

1. When caring for a geriatric client, the nurse must remember that the following change occurs as an individual ages:1. Subcutaneous tissue decreases.

2. Both the epidermis and the dermis thicken.

3. The number of Merkels cells and Langerhans cells increases.

4. Sebaceous gland activity increases.

Correct Answer: Subcutaneous tissue decreases

Rationale: Sebaceous gland activity decreases, resulting in the older individual having drier and more scaly skin. Both the epidermis and the dermis thin, making skin more susceptible to breakdown. The subcutaneous tissue decreases, so the client has less padding, which also makes the chance of skin breakdown greater. The number of Merkels cells and Langerhans cells decreases, which causes the older client to be more susceptible to infection. Cognitive Level: ApplicationNursing Process: Assessment

Client Need: Physiological IntegrityLO: 12. During a conversation with the nurse, the client comments that he rarely goes outside when the sun is shining because he is afraid of developing skin cancer. This would predispose the client for developing:

1. Vitamin D deficiency.2. Hypercholesterolemia.

3. Hypokalemia.

4. Hypernatremia.

Correct Answer: Vitamin D deficiency.

Rationale: The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol). Hypercholesterolemia results from factors such as dietary intake and cholesterol that is produced by the body. The skin does retard the loss of fluid and does play a role in fluid and electrolyte balance. Exposure to sunlight does cause both decreased potassium (hypokalemia) and increased sodium (hypernatremia).

Cognitive Level: AnalysisNursing Process: Assessment

Client Need: Physiological Integrity

LO: 13. An unconscious client whose identity is unknown is admitted to the emergency department. The most important role the skin of the client plays in helping to identify the client is to determine:

1. The race of the client.2. The age of the client.

3. Any injuries the client may have sustained.

4. The sex of the client.

Correct Answer: The race of the client.Rationale: The skin can help determine the identity of the patient; in addition to providing fingerprints, the amount of melanin or carotene pigments in the skin provides information regarding race. While changes in the skin that occur with aging may aid in estimating the age of the client, it is only an estimate because there are other external factors that affect the appearance of the skin. Determining the type of injuries sustained may be helpful in providing clues to the persons identity, but is not as significant as race in determining the identity. The skin does not play a role in determining the sex of a client.

Cognitive Level: Analysis

Nursing Process: Assessment


LO: 14. While taking a clients health history, the nurse learns that the client worked at a landfill for the last 35 years. This information is most significant because it could indicate:

1. Possible exposure to environmental toxins.

2. The clients lack of communication skills.

3. The client is elderly.

4. The clients level of education.

Correct Answer: Possible exposure to environmental toxins.Rationale: While all of the clients statements are important information to obtain when taking a health history, the clients occupation could involve exposure to such toxins as arsenic, coal tar, creosote, and/or petroleum products. Landfills are a risk factor for skin cancer.

Cognitive Level: ApplicationNursing Process: Assessment


LO: 25. One of the first steps in an assessment is determining the chief complaint. The chief complaint is:

1. The clients current issue.

2. Determined after the nurse does a complete health history.

3. Formulated by the nurse.

4. A vague description of a problem.

Correct Answer: The clients current issue.Rationale: The chief complaint is the clients current issue or reason for seeking health care. It is generally a concise statement in the clients own words. It is typically best elicited by the nurses asking the client what he or she considers to be the most current and acute health issue. The chief complaint is not determined by the nurse, nor is it a vague description of a problem. The chief complaint is expressed by the client, not determined after a complete health history.Cognitive Level: ApplicationNursing Process: Assessment


LO: 26. It is most essential that the nurse use skillful interviewing techniques while completing a health assessment of the skin, hair, and nails in order to:

1. Explore and investigate each symptom.

2. Gain the clients trust.

3. Discard unimportant data.

4. Speed up the interview.

Correct Answer: Explore and investigate each symptom.Rationale: Each symptom identified should be thoroughly described in order for the nurse to gain a full understanding. The nurse may ask the client questions such as, Tell me more about the problem, or How did the problem start? These types of questions will usually prompt the client to proceed with further information about the symptoms. Skillful interviewing techniques may gain the clients trust, discard unimportant data, and speed up the interview, but these are not as important as exploring and investigating symptoms.Cognitive Level: AnalysisNursing Process: Assessment


LO: 27. A client is admitted to the unit with swelling of both lower extremities. During the physical exam, the nurse palpates the clients skin with the pads of her fingers and finds that the indention formed is deep, but lasts only a short time. This finding indicates:

1. Pitting edema.

2. Loss of skin elasticity.

3. Decrease sensation.

4. Increased skin turgor.

Correct Answer: Pitting edema.Rationale: If pressure leaves an indentation in the skin, pitting edema is present. Edema is caused by accumulation of fluid in the intercellular spaces. Pitting edema is generally evaluated on a 4-point scale. Loss of skin elasticity causes the skin to lack firmness, but the skin does indent when palpated. A patient with edema does not have a decrease in sensation. Skin turgor is assessed by pinching the skin to determine how quickly it returns to its normal shape.Cognitive Level: ApplicationNursing Process: Assessment


LO: 38. When a nurse is conducting a physical examination of the skin, hair, and nails, the age of the client is an important factor because:

1. There are age-related changes.

2. Skin changes in the older population are pathologic.

3. Scaly, dry skin is common in young adults.

4. It is the most significant risk factor for cancer.

Correct Answer: There are age-related changes.Rationale: There are age-related changes. What is normal for a young person will be changed or absent in the older population. Skin changes related to the aging process are not always pathologic. The nurse must possess the knowledge of normal versus abnormal for each age group when discussing the skin. Age is not the most significant risk factor for cancer. Scaly, dry skin is not common in young adults. Cognitive Level: ApplicationNursing Process: Assessment

Client Need: Physiological IntegrityLO: 39. When performing a physical examination of a clients skin, the nurse should:

1. Be aware of ethnic differences.

2. Examine the least-exposed areas first.

3. Inspect the skin while the client is standing up.

4. Examine only the areas of specific concern.

Correct Answer: Be aware of ethnic differences.Rationale: Ethnic differences are important because of the difference in skin color. For example, in dark-skinned people the best areas to assess pallor, cyanosis, and jaundice are the oral mucous membranes and conjunctiva. The nurse should inspect the skin while the client is in a sitting or lying position and should begin by examining the most frequently exposed area first. A brief but careful look at the clients body should be done, and then areas of specific concern should be examined in detail.Cognitive Level: AnalysisNursing Process: Assessment


LO: 310. During a physical exam of the clients nails, the nurse depresses the nail edge to blanch and then releases it. This technique will allow the nurse to assess:

1. Capillary refill.

2. The clients nail bed.

3. How brittle the clients nails are.

4. If clubbing of the nail is present.

Correct Answer: Capillary refill.Rationale: The nail plate is translucent. To determine capillary refill, the nail edge is depressed to blanch and is released, noting the return of color. Capillary refill is usually documented as brisk, which is a normal response. Depressing the nail edge would have no effect on the nail bed. Brittle nails are diagnosed by looking at the distal plates of the nail to inspect for splitting and peeling of the nail. Clubbing is assessed by looking at the angle of the nail bed.Cognitive Level: ApplicationNursing Process: Assessment


LO: 411. Using correct technique for assessing a clients skin turgor, the nurse would:

1. Grasp a fold of the patients skin using the forefinger and thumb.

2. Palpate the skin.

3. Blanch the nail bed.

4. Determine the clients fluid intake for past 2 hours.

Correct Answer: Grasp a fold of the patients skin using the forefinger and thumb.Rationale: Turgor refers to the elasticity and mobility of the skin. Elasticity is the skins ability to return to a normal position and shape, and mobility is the skins ability to be lifted. To assess turgor, the nurse would grasp a fold of the patients skin using the forefinger and thumb. The nurse notes how rapidly the skin returns to its normal shape. Elasticity and mobility of the skin cannot be determined by palpating the skin. Blanching the nail bed assesses capillary refill, which indicates circulation in the extremity. Turgor is an indication of hydration, but will not indicate when or how much fluid has been taken.

Cognitive Level: ApplicationNursing Process: Assessment


LO: 412. The nurse must palpate the skin to assess the texture of the clients skin. The correct technique is to use the:

1. Palmer surface of the fingers and finger pads.

2. Dorsal surface of the hand.

3. Anterior surface of the wrist.

4. Palm of the hand.

Correct Answer: Palmer surface of the fingers and finger pads.Rationale: Palpation is the examination of the skin through the use of touch. The palmer surface of the fingers and finger pads should be used to assess the texture. Use of the palm or dorsal surface of the hand, or the anterior surface of the wrist, would not demonstrate correct technique.Cognitive Level: ApplicationNursing Process: Assessment


LO: 413. While performing the assessment for bilateral symmetrical skin temperature, the nurse finds that the clients left hand skin temperature is much cooler that the skin temperature of the right hand. This finding could indicate:

1. Peripheral arterial insufficiency.

2. Hypothyroidism.

3. Infection.

4. Overuse.

Correct Answer: Peripheral arterial insufficiency.Rationale: Peripheral arterial insufficiency decreases the blood flow to the area, which results in decreased local skin temperature. Hypothyroidism would cause a generalized decrease in skin temperature. An infection could cause an increase in localized skin temperature. Overuse is not likely to cause a difference in temperature.Cognitive Level: AnalysisNursing Process: Assessment


LO: 514. A client is admitted with edematous lower extremities. The nurse palpates the clients skin and finds that when pressure is applied, a deep indentation occurs and lasts for a short time. Based on a 4-point scale, this finding would be documented as:

1. 3+ pitting edema.2. 1+ pitting edema.3. 2+ pitting edema.4. 4+ pitting edema.Correct Answer: 3+ pitting edema.Rationale: On a 4-point scale, 3+ pitting edema describes deep pitting with the indentation lasting a short time. 1+ pitting edema describes mild pitting in which there is slight indentation and no obvious swelling. 2+ pitting edema indicates moderate pitting in which the indentation rapidly subsides. 4+ pitting edema describes very deep pitting in which the indentation lasts a long time.Cognitive Level: ApplicationNursing Process: Assessment


LO: 515. A client is very concerned about a vesicle on the lip that extends onto the skin. The patients history reveals this vesicle has been present for 3 days. After assessing the vesicle, the nurse concludes that the vesicle is probably:

1. A herpes infection.

2. Skin cancer.

3. Due to systemic dehydration.

4. Due to a recent injury.

Correct Answer: A herpes infection

Rationale: Herpes is a viral infection that presents with a vesicle on the lip that extends onto the skin. Skin cancer most commonly occurs on the lower lip or underside of the tongue and is suspected when there is an open area that does not heal. Systemic dehydration may be manifested in dry, scaling, cracking lips. A lesion from a recent injury would vary depending on the exact injury, and a history of the injury would be determined during the history.

Cognitive Level: ApplicationNursing Process: Diagnosis


LO: 516. The nurse discovers a vascular lesion on a clients chest. To help the nurse determine if the lesion is pectechie or telangiectasia, the nurse should check if the lesion:

1. Will blanch.

2. Is raised.

3. Is scaly.

4. Is painful.

Correct Answer: Will blanch.Rationale: Determining whether a lesion will blanch will help identify the type of lesion. Pectechie will not blanch, whereas telangiaectases will blanch. Neither pectechie nor telangiectasia is raised, scaly, or painful.Cognitive Level: AnalysisNursing Process: Assessment


LO: 617. A client with a history of chronic allergic dermatitis is concerned because of area where the skin had become thickened and rough. This type of lesion is:

1. Lichenification.

2. Excoriation.

3. Ulceration.

4. Ecchymosis.

Correct Answer: Lichenification.Rationale: Conditions such as chronic dermatitis can cause the epidermis to become rough and thickened. Superficial skin markings will also become more visible. Excoriation is an abrasion of the epidermis. Ulceration is a localized area of tissue necrosis. Ecchymosis is a red-purple discoloration of the skin.Cognitive Level: ApplicationNursing Process: Diagnosis


LO: 618. A 50-year-old client is concerned because several firm, deep-red papules have appeared on both legs and the number is increasing. The nurse recognizes these lesions as:

1. Cherry angiomas.

2. Purpura.

3. Venous stars.

4. Spider angiomas.

Correct Answer: Cherry angiomas.Rationale: A cherry angioma is a firm, deep-red papule and is a benign vascular lesion. It is generally found on most people after age 30, and the incidence increases with age. Purpura is a red-purple lesion that is greater than 0.5 centimeter in diameter and is caused by intravascular defects or infection. A venous star is a bluish irregular spider shape with linear lines and is caused by increased pressure in superficial veins. A spider angioma has a red central body with radiating spider-like legs and can be caused by liver disease or vitamin B deficiency.Cognitive Level: ApplicationNursing Process: Diagnosis


LO: 619. The nurse notes a yellowish discoloration of the clients skin, but it does not involve the sclera or mucous membranes. The nurse should question the client about:

1. Dietary intake.

2. History of hepatitis.

3. Ethnicity.

4. Food allergies.

Correct Answer: Dietary intake.Rationale: The yellowish discoloration of the clients skin could be carotenemia. It is often associated with a high intake of foods with carotene (sweet potatoes, squash, and carrots). Jaundice associated with liver involvement will usually involve the sclera of the eyes. Asians have a higher level of carotene in their skin, which causes a yellow hue to the skin, but it does not cause a yellowish discoloration. Food allergies do not cause discoloration of the skin, but will usually cause a reaction such as a rash or urticaria.Cognitive Level: AnalysisNursing Process: Assessment


LO: 720. While palpating the nail bed of an African American client, the nurse notes that the clients nails have linear bands along the nail edge. This finding:

1. Is found in dark-skinned individuals.

2. Indicates a fungal infection of the nail bed.

3. Indicates a nutritional deficiency.

4. Indicates the client is cyanotic.

Correct Answer: Is found in dark-skinned individuals

Rationale: The nail plate is translucent and the nurse should expect to see a pink nail bed. Dark-skinned individuals may have brownish pigmented areas or linear bands along the nail edge. A fungal infection of the nail usually causes deformed, cracked nails that turn yellow or brown. A vitamin deficiency may cause nails to have pits, transverse grooves, or lines. The nail beds of a client who is cyanotic will have a bluish hue. The nail beds of dark-skinned clients may appear have an ashen-gray hue.Cognitive Level: ApplicationNursing Process: Assessment


LO: 721. A client from Southeast Asia who has been ill with influenza is admitted with self-inflicted open sores and bruising on both forearms. When questioned about the wounds, the client stated that it was done to aid in the healing process. The nurse should recognize:

1. This may be a cultural practice.

2. The client is delusional.

3. The client belongs to a cult.

4. The cause of the wounds is unimportant.

Correct Answer: This may be a cultural practice.Rationale: It is important to determine the cause of the wounds. This clients actions may indicate a cultural practice. It is important for the nurse to inquire about any cultural habits or practices that may affect the patients skin. This is an opportunity for the nurse to educate the client regarding safe health practices while being nonjudgmental. A client who performs a cultural health practice is not delusional; it is part of the culture. Cultural practices are not related to a client being a member of a cult. Cognitive Level: ApplicationNursing Process: Assessment


LO: 7Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

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