Chapter 26: Assessment of the Skin, Hair, and Nails

Chapter 26: Assessment of the Skin, Hair, and Nails

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms. What is the client’s priority problem?

a.	Risk for injury
b.	Infection
c.	Poor self-image
d.	Discomfort

 

 

ANS:  A

Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk for injury in response to even minimal trauma or shearing events. If injury occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take priority over the risk for injury.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC:  Integrated Process: Nursing Process (Planning)

 

2. A client has a suspected superficial fungal infection. The nurse prepares the client for a culture by explaining the procedure. Which statement by the client indicates a correct understanding of the procedure?

a.	“The doctor will shave off a small piece of the lesion.”
b.	“You will be performing what is called a punch biopsy.”
c.	“A sample is obtained by simply scraping the lesion.”
d.	“You’ll squeeze material from the lesion to send to the laboratory.”

 

 

ANS:  C

A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade. The other techniques are not used for a suspected superficial fungal infection.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)    MSC:           Integrated Process: Teaching/Learning

 

3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation, what is the nurse’s best action?

a.	Evaluate the client further for hepatitis.
b.	Examine the soles of the client’s feet.
c.	Inspect the client’s oral mucosa.
d.	Place the client in contact isolation.

 

 

ANS:  C

The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits that show a yellow hue. Before considering hepatitis, the nurse must do a more thorough assessment. The soles of the feet may appear yellow simply from calluses, so this is not the best place to assess. No need to isolate the client has been identified.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:           Integrated Process: Nursing Process (Assessment)

 

4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data, what does the nurse do next?

a.	Take a medication history.
b.	Assess pulse oximetry.
c.	Assess the client’s personal hygiene.
d.	Palpate the soles and palms.

 

 

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 conjunctivae have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments)           MSC:              Integrated Process: Nursing Process (Assessment)