Med Surg - ed 8 - Chapter 24: Assessment of the Skin, Hair, and Nails

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Question 1 of 1

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While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous membranes. Which action should the nurse take next?

Select the correct answer(s).

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Explanation

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 a

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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?

Select the correct answer(s).

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Explanation

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.

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A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

Select the correct answer(s).

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Explanation

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.

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After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client’s understanding. Which statement indicates the client has a good understanding of this condition?

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Explanation

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

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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 client’s skin. How should the nurse document these lesions?

Select the correct answer(s).

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Explanation

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

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While assessing a client’s lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?

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Explanation

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 client’s limb could be threatened.

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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?

Select the correct answer(s).

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Explanation

Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the client’s skin changes are affecting the client’s body image and encourage the client to express his or her feelings

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A nurse assesses a client who has open lesions. Which action should the nurse take first?

Select the correct answer(s).

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Explanation

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.

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A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?

Select the correct answer(s).

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Explanation

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 ov

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A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?

Select the correct answer(s).

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Explanation

Pallor conjunctivae signifies anemia. The nurse should assess the client’s hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client’s potential anemia.

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During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client’s chest. Which descriptors should the nurse use to document these observations?

Select the correct answer(s).

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Explanation

“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

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A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all that apply.)

Select the correct answer(s).

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Explanation

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

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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 client’s plan of care? (Select all that apply.)

Select the correct answer(s).

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Explanation

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 client’s nutritional status, the nurse should ass

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A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

Select the correct answer(s).

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Explanation

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.

Med Surg - ed 8 - Chapter 24: Assessment of the Skin, Hair, and Nails

Question 1 of 1

Time Left

While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous membranes. Which action should the nurse take next?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

Select the correct answer(s).

(0/0)

Explanation

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client’s understanding. Which statement indicates the client has a good understanding of this condition?

Select the correct answer(s).

(0/0)

Explanation

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 client’s skin. How should the nurse document these lesions?

Select the correct answer(s).

(0/0)

Explanation

While assessing a client’s lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

A nurse assesses a client who has open lesions. Which action should the nurse take first?

Select the correct answer(s).

(0/0)

Explanation

A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?

Select the correct answer(s).

(0/0)

Explanation

A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?

Select the correct answer(s).

(0/0)

Explanation

During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client’s chest. Which descriptors should the nurse use to document these observations?

Select the correct answer(s).

(0/0)

Explanation

A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

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 client’s plan of care? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

Select the correct answer(s).

(0/0)

Explanation

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