Chapter 22: Assessment of the Skin, Hair,
and Nails
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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 will 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 will assess how the client’s skin changes are affecting
his or her body image and encourage the client to express feelings about a change in
appearance. The other statements are dismissive of the client’s concerns.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Skin, hair, and nail, Assessment, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
2. A nurse assesses a client who has open skin lesions. Which action by the nurse is most
important?
a. Put on gloves.
b. Ask the client about his or her occupation.
, c. Assess the client’s pain.
d. Obtain vital signs.
ANS: A
Nurses wear gloves as part of Standard Precautions when examining skin that is not
intact. The other options are part of the full assessment but adhering to Standard
Precautions is important for safety and infection control.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Standard Precautions
MSC: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse reads on a chart that a client has lichenification. What assessment finding
confirms this description?
a. Increased skin thickness
b. Excessive facial hair
c. Purple skin patches
d. Tightly stretched skin
ANS: A
Lichenification is increased skin thickness as the result of scarring. Excessive facial
hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly
stretched skin is from edema.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client and identifies that the client has pale conjunctivae. Which
focused assessment will the nurse complete next?
a. Partial thromboplastin time
and Nails
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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 will 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 will assess how the client’s skin changes are affecting
his or her body image and encourage the client to express feelings about a change in
appearance. The other statements are dismissive of the client’s concerns.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Skin, hair, and nail, Assessment, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
2. A nurse assesses a client who has open skin lesions. Which action by the nurse is most
important?
a. Put on gloves.
b. Ask the client about his or her occupation.
, c. Assess the client’s pain.
d. Obtain vital signs.
ANS: A
Nurses wear gloves as part of Standard Precautions when examining skin that is not
intact. The other options are part of the full assessment but adhering to Standard
Precautions is important for safety and infection control.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Standard Precautions
MSC: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
3. The nurse reads on a chart that a client has lichenification. What assessment finding
confirms this description?
a. Increased skin thickness
b. Excessive facial hair
c. Purple skin patches
d. Tightly stretched skin
ANS: A
Lichenification is increased skin thickness as the result of scarring. Excessive facial
hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly
stretched skin is from edema.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client and identifies that the client has pale conjunctivae. Which
focused assessment will the nurse complete next?
a. Partial thromboplastin time
