Iggy 10th Medical Surgical Nursing- Hair,
Skin & Nails
1. While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and
mucous membranes. Which action will the nurse take next?
a. Ask the client about current medications he or she is taking.
b. Use pulse oximetry to assess the patient's oxygen saturation.
c. Auscultate the patient's lung fields for adventitious sounds.
d. Palpate the patient's bilateral radial and pedal pulses. - ANSANS: 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 will assess for systemic oxygenation before continuing with other assessments.
2. A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which
question will 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?" - ANSANS: 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.
3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which
question will 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?" - ANSANS: 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.
4. 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?
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."
d. "I will schedule a mammogram as soon as I can." - ANSANS: 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.
5. A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the
size
of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell
the client regarding these lesions?
a. "Monitor these spots for any changes."
b. "You don't need to worry about these."
c. "I will ask for a dermatology referral for you."
d. "We need to schedule you for a skin biopsy." - ANSANS: A
Because of melanocyte hyperplasia, the older adult frequently has "age spots," or darker
spots
on the skin. The nurse would teach the client to monitor the spots and report any changes
indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive.
The client does not necessarily need a dermatology referral and does not need a skin biopsy
at
this point.
6. 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." - ANSANS: 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.
7. 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. - ANSANS: 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.
8. 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
Skin & Nails
1. While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and
mucous membranes. Which action will the nurse take next?
a. Ask the client about current medications he or she is taking.
b. Use pulse oximetry to assess the patient's oxygen saturation.
c. Auscultate the patient's lung fields for adventitious sounds.
d. Palpate the patient's bilateral radial and pedal pulses. - ANSANS: 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 will assess for systemic oxygenation before continuing with other assessments.
2. A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which
question will 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?" - ANSANS: 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.
3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which
question will 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?" - ANSANS: 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.
4. 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?
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."
d. "I will schedule a mammogram as soon as I can." - ANSANS: 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.
5. A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the
size
of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell
the client regarding these lesions?
a. "Monitor these spots for any changes."
b. "You don't need to worry about these."
c. "I will ask for a dermatology referral for you."
d. "We need to schedule you for a skin biopsy." - ANSANS: A
Because of melanocyte hyperplasia, the older adult frequently has "age spots," or darker
spots
on the skin. The nurse would teach the client to monitor the spots and report any changes
indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive.
The client does not necessarily need a dermatology referral and does not need a skin biopsy
at
this point.
6. 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." - ANSANS: 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.
7. 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. - ANSANS: 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.
8. 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
