Chapter 24 Assessment of the Skin, Hair, and Nails PDF

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Chapter24:AssessmentoftheSkin,Hair,andNails MULTIPLECHOICE 1.Whileassessingaclient,anursedetectsabluishtingetotheclientspalms,soles,andmucousmembranes. Whichactionshouldthenursetakenext? a.Asktheclientaboutcurrentmedicationsheorsheistaking. b.Usepulseoximetrytoassesstheclientsoxygensaturation. c.Auscultatetheclientslungfieldsforadventitioussounds. d.Palpatetheclientsbilateralradialandpedalpulses. 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mucousmembraneshaveabluishtinge.Thenurseshouldassessforsystemic oxygenationbeforecontinuingwithotherassessments. DIF:Applying/ApplicationREF:438 KEY:Cyanosis MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 2.Anurseassessesaclientwhoisadmittedwithinflamedsoft-tissuefoldsaroundthenailplates.Which questionshouldthenurseasktoelicitusefulinformationaboutthepossiblecondition? a.Whatdoyoudoforaliving? b.Areyournailsprofessionallymanicured? c.Doyouhavediabetesmellitus? d.Haveyouhadarecentfungalinfection? ANS:A Theconditionchronicparonychiaiscommoninpeoplewithfrequentintermittentexposuretowater,suchas homemakers,bartenders,andlaundryworkers.Theotherquestionswouldnotprovideinformationspecifically relatedtothisassessmentfinding. DIF:Applying/ApplicationREF:443 KEY:Infection MSC:IntegratedProcess:NursingProcess:Analysis NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 3.Anurseassessesaclientwhohasmultipleareasofecchymosisonbotharms.Whichquestionshouldthe nurseaskfirst? a.Areyouusinglotiononyourskin? b.Doyouhaveafamilyhistoryofthis? c.Doyourarmsitch? d.Whatmedications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:Applying/ApplicationREF:440 KEY:Medications|adverseeffects MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 4.Afterteachingaclientwhoexpressedconcernaboutarashlocatedbeneathherbreast,anurseassessesthe clientsunderstanding.Whichstatementindicatestheclienthas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.

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d.IwillscheduleamammogramassoonasIcan. ANS:C Rasheslimitedtoskinfold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.Fluidoverloadandbreastcancerarenotrelated torashesinskinfolds. DIF:Applying/ApplicationREF:440 KEY:Skinbreakdown|hygieneMSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:HealthPromotionandMaintenance 5.Anurseassessesaclientwhohastwoskinlesionsonhischest.Eachlesionisthesizeofanickel,flat,and darkerincolorthantheclientsskin.Howshouldthenursedocumenttheselesions? 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:Applying/ApplicationREF:439 KEY:Skinlesions/wounds|documentation MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 6.Whileassessingaclientslowerextremities,anursenoticesthatonelegispaleandcoolertothetouch. Whichassessmentshould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:Applying/ApplicationREF:441 KEY:Vascularperfusion MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 7.Anursecaresforanolderadultclientwhohasachronicskindisorder.Theclientstates,Ihavenotbeento churchinseveralweeksbecauseofthediscolorationofmyskin.Howshouldthenurserespond? a.Iwillconsultthechaplaintoprovideyouwithspiritualsupport. b.Youdonotneedtogotochurch;Godiseverywhere. c.Tellmemoreaboutyourconcernsrelatedtoyourskin. d.Religiouspeoplearenonjudgmentalandwillacceptyou. ANS:C Clientswithchronicskindisordersoftenbecomesociallyisolatedrelatedtothefearofrejectionbyothers. Nursesshouldassesshowtheclientsskinchangesareaffectingtheclientsbodyimageandencouragetheclien toexpresshisorherfeelingsaboutachangeinappearance.Theotherresponsesarenotappropriate.

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DIF:Applying/ApplicationREF:444 KEY:Support|coping MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:PsychosocialIntegrity 8.Anurseassessesaclientwhohasopenlesions.Whichactionshouldthenursetakefirst? a.Putongloves. b.Asktheclientabouthisorheroccupation. c.Assesstheclientspain. d.Obtainvitalsigns. ANS:A NursesshouldwearglovesaspartofStandardPrecautionswhenexaminingskinthatisnotintact.Theother optionsshouldbecompletedafterglovesareputon. DIF:Remembering/KnowledgeREF:445 KEY:StandardPrecautions|skinlesions/wounds MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 9.Anurseassessesaclientwhohasachronicskindisorder.Whichfindingindicatestheclientiseffectively copingwiththedisorder? a.Cleanhairandnails b.Pooreyecontact c.Disheveledappearance d.Drapesascarfovertheface ANS:A Thenurseshouldcompleteapsychosocialassessmenttodetermineiftheclientiscopingeffectively.Signsof adequatecopingincludecleanhair,skin,andnails;goodeyecontact;andbeingsociallyactive.Adisheveled appearanceanddrapingascarfoverthefacetohidetheclientsappearancedemonstratethattheclientmaybe havingdifficultycopingwithhisorhercondition. DIF:Understanding/ComprehensionREF:444 KEY:Skinlesions/wounds|coping MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PsychosocialIntegrity 10.Anurseassessesaclientandidentifiesthattheclienthaspallorconjunctivae.Whichfocusedassessment shouldthenursecompletenext? a.Partialthromboplastintime b.Hemoglobinandhematocrit c.Liverenzymes d.Basicmetabolicpanel ANS:B Pallorconjunctivaesignifiesanemia.Thenurseshouldassesstheclientshemoglobinandhematocrittoconfirm anemia.Theotherlaboratoryresultsdonotrelatetothisclientspotentialanemia. DIF:Applying/ApplicationREF:438 KEY:Anemia MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 11.Duringskininspectionofaclient,anurseobserveslesionswithwavybordersthatarewidespreadacross theclientschest.Whichdescriptorsshouldthenurseusetodocumenttheseobservations? a.Clusteredandannular b.Linearandcircinate c.Diffuseandserpiginous

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d.Coalescedandcircumscribed ANS:B Diffuseisusedtodescribelesionsthatarewidespread.Serpiginousdescribeslesionswithwavyborders. Clustereddescribeslesionsgroupedtogether.Lineardescribeslesionsoccurringinastraightline.Annular lesionsareringlikewithraisedborders,circinatelesionsarecircular,andcircumscribedlesionshavewelldefinedsharpborders.Coalesceddescribeslesionsthatmergewithoneanotherandappearconfluent. DIF:Remembering/KnowledgeREF:438 KEY:Skinlesions/wounds|documentation MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 12.Anurseassessesanolderadultclientwiththeskindisordershownbelow: Howshouldthenursedocumentthisfinding? a.Petechiae b.Ecchymoses c.Actiniclentigo d.Senileangiomas ANS:A Petechiae,orsmall,reddishpurplenonraisedlesionsthatdonotfadeorblanchwithpressure,arepicturedhere Ecchymosesarelargerareasofhemorrhaging,commonlyknownasbruising.Actiniclentigopresentsaspaperthin,transparentskin.Senileangiomas,alsoknownascherryangiomas,areredraisedlesions. DIF:Remembering/KnowledgeREF:438 KEY:Skinlesions/wounds|documentation MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation MULTIPLERESPONSE 1.Anurseassessesanolderadultsskin.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lesionwithvariouscolors,aswellastheasymmetric6-mmdarklesion,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:Applying/ApplicationREF:437 KEY:Collaboration|skinlesions/wounds|olderadult MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 2.Anurseplanscareforaclientwhohasawoundthatisnothealing.Whichfocusedassessmentsshouldthe nursecompletetodeveloptheclientsplanofcare?(Selectallthatapply.) a.Height b.Allergies c.Alcoholuse d.Prealbuminlaboratoryresults e.Liverenzymelaboratoryresults

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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ANS:A,C,D Nutritionalstatuscanhaveasignificantimpactonskinhealthandwoundhealing.Thecareplanforaclient withpoornutritionalstatusshouldincludeahigh-protein,high-caloriediet.Todeterminetheclientsnutritiona status,thenurseshouldassessheightandweight,alcoholuse,andprealbuminlaboratoryresults.Thesedata willprovideinformationrelatedtovitaminandproteindeficiencies,andobesity.Allergiesandliverenzyme laboratoryresultswillnotprovideinformationaboutnutritionstatusorwoundhealing. DIF:Applying/ApplicationREF:436 KEY:Skinlesions/wounds|nutrition MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 3.Anurseteachesaclienttoperformtotalskinself-examinationsonamonthlybasis.Whichstatementsshould thenurseincludeinthisclientsteaching?(Selectallthatapply.) a.Lookforasymmetryofshapeandirregularborders. b.Assessforcolorvariationwithineachlesion. c.Examinethedistributionoflesionsoverasectionofthebody. d.Monitorforedemaorswellingoftissues. e.Focusyourassessmentonskinareasthatitch. ANS:A,B ClientsshouldbetaughttoexamineeachlesionfollowingtheABCDEfeaturesassociatedwithskincancer: asymmetryofshape,borderirregularity,colorvariationwithinonelesion,diametergreaterthan6mm,and evolvingorchanginginanyfeature. DIF:Applying/ApplicationREF:437 KEY:Skinlesions/woundsMSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:HealthPromotionandMaintenance...