Exam 13: Skin, Hair, Nails

The nurse is assessing the skin of a newborn and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which response by the nurse is the most appropriate?

The nurse is preparing a client for a detailed assessment of the integumentary system. Which statements by the nurse are useful to prepare the client for this examination?

The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which response by the nurse is the most appropriate?

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?

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

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?

While performing a skin assessment for a client, the nurse notes that the client becomes pales and diaphoretic. The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76 mmHg, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which is the priority response by the nurse?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client's left arm. The client states, "I had a burn here a long time ago, but it seemed to keep on getting bigger." Which term will the nurse use when documenting this finding in the client's medical record?

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?