Integumentary Assessment Flashcards
The nurse questions the client about her symptoms. What should the nurse ask about first?
History of skin conditions.
What the client has done to treat the itching.
Severity and location of the itching.
Recent exposure to lice or scabies.
Severity and location of the itching.
This is the priority question. Itching may be a symptom of a more life threatening problem and the severity needs to be assessed as a priority.
The nurse questions the client about anaphylaxis. What client cues would indicate the presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be correct.)
Select all that apply
Drooling.
Shortness of breath.
Diaphoresis.
Flushed or pale skin.
Tremors or seizures.
Drooling.
Drooling is a symptom of a closing airway in an adult client. Closing of the airway may occur during anaphylaxis.
Shortness of breath.
Shortness or breath or wheezing may be present if the airway is compromised due to anaphylaxis.
Flushed or pale skin.
Skin may be flushed or pale related to the reaction.
The nurse prepares to administer diphenhydramine 50 mg orally. The tablet is supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value only. If rounding is necessary, round to the tenth.)
D/H = X
50 mg/ 25 mg = 2
The nurse teaches the client about diphenhydramine. Which information should the nurse include? (Select all that apply. One, some, or all options may be correct.)
Select all that apply
Diphenhydramine blocks the effect of the histamine response to reduce itching.
Diphenhydramine products contain aspirin, so observe for signs of bleeding.
This medication may cause drowsiness.
Blurred vision or loss of balance are potentially serious side effects of this medication.
This medication may cause an increase in secretions and moisten mucous membranes.
Diphenhydramine blocks the effect of the histamine response to reduce itching.
Diphenhydramine is a H1 receptor antagonist and may be helpful to reduce itching associated with hives.
This medication may cause drowsiness.
Although considered a minor side effect, diphenhydramine may cause drowsiness.
Blurred vision or loss of balance are potentially serious side effects of this medication.
The client should be taught to notify a health care provider if these uncommon but potentially serious side effects occur.
The nurse begins her assessment of the integumentary system. Select the techniques the nurse should perform.
Select all that apply
Percussion.
Palpation.
Inspection.
Auscultation.
Palpation.
The nurse should inspect and palpate the skin and appendages, such as hair and nails, as well as the mucous membranes.
Inspection.
The nurse should inspect and palpate the skin and appendages, such as hair and nails, as well as the mucous membranes.
The nurse observes that the client’s skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess?
Earlobes.
Hair follicles.
Cheeks and chin.
Conjunctivae.
Conjunctivae.
Because paleness of the skin can be difficult to detect in persons with dark or tanned skin, the membranes that line the eyelids (conjunctivae) are a good area to assess for pallor.
What action should the nurse perform if rapid facial flushing is observed?
Observe the color of the sclerae.
Measure the oxygen saturation.
Check for loss of skin integrity.
Ask about any feelings of anxiety.
Ask about any feelings of anxiety.
Rapid facial and neck flushing are often the result of vasodilation secondary to stress or anxiety.
The nurse observes that there are numerous blackheads around client’s chin and nose. What action should the nurse take in response to this finding?
Note any pustules or nodules.
Ask about a history of eczema.
Measure for pitting edema.
Palpate the areas for tenderness.
Note any pustules or nodules.
Blackheads are a form of acne, common in the adolescent when sebaceous gland activity increases. The nurse should look for signs of severe acne, which may be manifested as pustules or nodules on other parts of the client’s body (such as the back or chest).
What health promotion question is most important for the nurse to ask the client?
“Do you tend to bite or chew your nails?”
“What do you use to cleanse your skin?”
“How often do you use a tanning booth?”
“Do you use a hair coloring product?”
“How often do you use a tanning booth?”
Excessive use of a tanning booth increases the risk for skin cancer. Therefore, this is the most important question for the nurse to ask the client. The client states that she goes to a tanning booth once or twice a month.
What cues support the nurse’s assessment regarding the client’s fluid status?
Areas of skin bruising.
Rapid facial flushing.
Dry mucus membranes.
Shiny appearance of the forehead.
Dry mucus membranes.
Dry or cracked mucus membranes can be the result of inadequate hydration, which, like inelastic skin turgor, validates the initial finding of fluid volume deficit.
The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask? (Select all that apply. One, some, or all options may be correct.)
Select all that apply
“Have you experienced nausea or vomiting recently?”
“How much water are you drinking per day?”
“Have you experienced diarrhea recently?”
“Are you feeling dizzy?”
“Is your mouth dry?”
“Have you experienced diarrhea recently?”
Diarrhea can cause loss of fluid resulting in fluid volume deficit.
The nurse observes multiple moles on the client’s skin. What question is most important to ask the client?
“When did you first notice the presence of the moles?”
“Do the moles on your arms make you feel self-conscious?”
“Where are all your moles located?”
“Have any of your moles changed in size or appearance?”
“Have any of your moles changed in size or appearance?”
Because a change in the size or appearance of a mole is a danger sign for skin cancer and warrants a referral for medical evaluation, this is the most important question for the nurse to ask.
What additional observation is important in assessing the mole?
The border of the mole is smooth.
The mole is surrounded by freckles.
There is no inflammation around the mole.
The mole does not blanche when compressed.
The border of the mole is smooth.
Border regularity is an important finding because border irregularity may be a cancer danger sign.
The nurse observes that the nail surface is slightly curved and the angle of the nail base is 160 degrees. What action should the nurse take in response to this finding?
Ask the client about any current or past use of cigarettes.
Continue the assessment, noting the color of the nail surface.
Use a pulse oximeter to measure the oxygen saturation.
Assess for the presence of Beau’s lines.
Continue the assessment, noting the color of the nail surface.
A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface.
While assessing the client’s nails, it is most important for the nurse to follow up on which assessment finding?
Brittle nail surface.
Ragged cuticles.
Firm nail base.
Traumatized nail folds.
Brittle nail surface.
Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client’s nutritional status.
