Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 12 Skin, Hair, and Nails

1. The educator has reviewed the layers of skin with a nurse. Which statement indicates further teaching is required?

1. "The cutaneous glands help protect against bacteria on the skin."

2. "The subcutaneous tissue contains half of the body's fat cells."

3. "The dermis contains collagen and elastin fibers."

4. "The epidermis produces melanin."

Page Ref: 171

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails.

MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

1. Which structure of the nail protects the root of the nail?

1. Lunula.

2. Cuticle.

3. Posterior nail fold.

4. Nail matrix.

Page Ref: 172

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails.

MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

1. The nurse is conducting a focused interview on the client's integumentary system. Which questions should the nurse ask to identify risk factors for the development of integumentary disorders? Select all that apply.

1. "How much time do you spend outdoors?"

2. "How do you care for your skin?"

3. "Do you have any tattoos or body piercings?"

4. "Have you noticed any drainage from your skin?"

5. "Do you take any medications on a regular basis?"

Page Ref: 173

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview.

MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.

1. A client asks the nurse what the risk factors are for piercing the naval area. Which information should the nurse recognize is most important?

1. "You are at risk for scar tissue at the site."

2. "The piercing may get caught on clothing."

3. "You may not want the piercing in a few years."

4. "You are at risk for hepatitis A."

Page Ref: 176

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

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

1. Percussion.

2. Palpation.

3. Auscultation.

4. Inspection.

Page Ref: 180

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.

1. The nurse observes that a client's skin is pale. Which assessment data should the nurse anticipate is associated with the observation? Select all that apply.

1. Blood pressure is 96/62.

2. The client states, "I just smoked a cigarette before I came in the office."

3. Oxygen saturation level is 86% on room air.

4. The client states, "I have been diagnosed with osteoporosis."

5. The client states, "It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit."

Page Ref: 180

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.

1. 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?

1. Uremia.

2. Cyanosis.

3. Jaundice.

4. Carotenemia.

Page Ref: 180

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. 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 should the nurse use when documenting the finding?

1. Vesicle.

2. Macule.

3. Papule.

4. Tumor.

Page Ref: 191

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is assessing a client's nails for clubbing. Which technique should the nurse use?

1. Place two thumbs touching side-by-side.

2. Place two of the same fingers from each hand together.

3. Place two index fingers together tip-to-tip.

4. Place the hands out straight with the palm sides down.

Page Ref: 189

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.

1. A client asks the nurse why they are growing facial hair. Which statement should the nurse provide the patient?

1. "Your diet is not nutritionally balanced."

2. "You may have some hormone imbalances."

3. "Usually, there is not a known cause for this condition."

4. "You may be lacking particular vitamins."

Page Ref: 188

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is inspecting the fingernails of a client who is diagnosed with polycythemia. Which assessment data would be expected for this client?

1. Dark red nails.

2. Horizontal white bands.

3. Pale nail beds.

4. Spoon-shaped nails.

Page Ref: 188

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. An adolescent client tells the nurse that they shower daily but still have a skin odor. Which action should the nurse take?

1. Reassure the adolescent that this is normal.

2. Notify the client's healthcare provider.

3. Recommend a strong body wash product.

4. Educate the client regarding the importance of increased water intake.

Page Ref: 174

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

1. The nurse is providing education to a postpartum client. Which should the nurse include in the teaching about the client's hair?

1. "You may notice an increase in the dryness of your hair."

2. "Due to the hormonal changes, the thickness of your hair may increase."

3. "You may notice that your hair will shed for up to several months."

4. "Hormones may alter melanocyte production slightly altering your hair color."

Page Ref: 177

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

1. The nurse notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size on the client's skin. Which term should the nurse use to document the finding?

1. Vesicle.

2. Bulla.

3. Papule.

4. Tumor.

Page Ref: 191

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek during an assessment. Which condition should the nurse suspect the client is experiencing?

1. Chickenpox.

2. Contact dermatitis.

3. Herpes simplex.

4. Psoriasis.

Page Ref: 199

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse notes that the client's skin, nails, and mucous membranes are very light in color. Which description should the nurse use to document the findings?

1. Cyanosis.

2. Pallor.

3. Erythema.

4. Jaundice.

Page Ref: 180

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse notes a client has several abdominal lesions that appear in distinct clusters. Which terminology should the nurse use when documenting the pattern of the lesions?

1. Grouped.

2. Annular.

3. Discrete.

4. Confluent.

Page Ref: 197

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is preparing to document herpetic lesions noted on a client. Which terms should the nurse use to document the finding? Select all that apply.

1. Vesicular.

2. Pustular.

3. Pruritic.

4. Ulcerated.

5. Crusty.

Page Ref: 199

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse reviewing a client record notes a documented finding of "+1 edema right lower leg." Which assessment finding should the nurse expect?

1. The presence of slight pitting, no obvious distortion.

2. Deep pitting, obvious distortion.

3. Pitting is obvious and extremities are swollen.

4. Moderate amount of edema.

Page Ref: 184

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse reviewing a client record notes a documented finding of "vitiligo present bilateral hands." Which assessment finding should the nurse anticipate?

1. Nodules with ulcerations.

2. Dark, asymmetrical colored patches.

3. Grouped vesicles.

4. Abnormal loss of melanin in patches.

Page Ref: 182

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is preparing to assess a client suspected of having a fungal nail infection. Which question should the nurse include in the assessment?

1. "Have you recently been ill?"

2. "Do you submerge your hands in water for long periods of time?"

3. "Have you recently changed anything in your dietary intake?"

4. "Do you take any over-the-counter medications or prescriptions?"

Page Ref: 178

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview.

MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.

1. A mother of a newborn infant calls the clinic and states, "I think my baby has jaundice." Which question should the nurse ask the mother?

1. "Does your baby have tiny, white facial bumps?"

2. "Does your baby's skin and mucous membranes have a yellowish color?"

3. "Does your baby have irregular red patches on the back of the neck?"

4. "Does your baby have dark spots on the area above the buttock?"

Page Ref: 180

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview.

MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.

1. The nurse is preparing to assess a client with darker skin for jaundice. Which assessment technique should the nurse use?

1. Use a bright lamp and a magnifying glass.

2. Press the client's skin and observe for blanching.

3. Assess the skin the same way you would inspect a client with lighter skin.

4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.

Page Ref: 180

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.

1. The nurse is assessing the skin of a client with hypothyroidism. Which findings should the nurse anticipate?

1. Excessively smooth skin.

2. Thin, shiny skin.

3. Rough, scaly skin.

4. Diaphoretic skin.

Page Ref: 183

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse notes an elevated irregular darkened area of excess scar tissue on a client. Which term should the nurse use to document the finding?

1. Ulcer.

2. Keloid.

3. Fissure.

4. Scar.

Page Ref: 192

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. A client that has had abdominal surgery one month prior expresses concern that the scar is "purplish." Which response should the nurse provide?

1. "Having a scar is unavoidable."

2. "The color is normal and will fade with time."

3. "You can have plastic surgery to remove the scar later."

4. "Everyone's skin heals a little bit differently."

Page Ref: 193

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is preparing to assess a client with a stage pressure III ulcer. Which findings should the nurse anticipate?

1. Ulcer involving muscle and bone.

2. Ulcer that extends into the subcutaneous tissue.

3. Involvement of the epidermal skin layer that may extend into the dermis.

4. A reddened area with skin intact and no involvement of the tissues

Page Ref: 185

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is preparing to asses a client with polycythemia. Which assessment finding in the client's nails should the nurse anticipate?

1. Pale.

2. Horizontal white bands.

3. Dark red.

4. A single nail with a darkly pigmented band.

Page Ref: 188

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. A client tells the nurse they have been stung by a bee. Which skin assessment findings should the nurse anticipate?

1. Bullae.

2. Plaque.

3. Wheal.

4. Vesicle.

Page Ref: 191

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse observes flat bright red dots with tiny radiating blood vessels of various sizes during a skin assessment of an adult client. Which should the nurse document the findings as in the client's record?

1. Spider angioma.

2. Purpura.

3. Hemangioma.

4. Hematoma.

Page Ref: 194

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.

1. The nurse is preparing a client for a detailed assessment of the integumentary system. Which instruction should the nurse provide the client? Select all that apply.

1. "Please remove all jewelry so that I can conduct a full assessment."

2. "I will turn the temperature down in the exam room before we begin."

3. "Use this blanket to cover up until we are ready to begin."

4. "I will be touching your skin as part of the process."

5. "I will need you to take off your head dress for the entire examination."

Page Ref: 179

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails.

MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.