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

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

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. 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?
   1. Ask the client about current medications he or she is taking.
   2. Use pulse oximetry to assess the client’s oxygen saturation.
   3. Auscultate the client’s lung fields for adventitious sounds.
   4. Palpate the client’s 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: 422                    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?
   1. “What do you do for a living?”
   2. “Are your nails professionally manicured?”
   3. “Do you have diabetes mellitus?”
   4. “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: 427                    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?
   1. “Are you using lotion on your skin?”
   2. “Do you have a family history of this?”
   3. “Do your arms itch?”
   4. “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:    424

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 client’s understanding. Which statement indicates the client has a good understanding of this condition?
   1. “This rash is probably due to fluid overload.”
   2. “I need to wash this daily with antibacterial soap.”
   3. “I can use powder to keep this area dry.”
   4. “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:    424                   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 client’s skin. How should the nurse document these lesions?
   1. Two 2-cm hyperpigmented patches
   2. Two 1-inch erythematous plaques
   3. Two 2-mm pigmented papules
   4. 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:    423       KEY: Skin lesions/wounds| documentation                            MSC: Integrated Process: Communication and Documentation  NOT:       Client Needs Category: Physiological Integrity: Physiological Adaptation