Health Assessment: Assessing Skin, Hair, And Nails
Health Assessment: Assessing Skin, Hair, and Nails
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Health Assessment: Assessing Skin, Hair, and Nails Chapter 13 Questions And Answers Latest Updates
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Health Assessment: Assessing Skin, Hair, and Nails
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Health Assessment: Assessing Skin, Hair, And Nails
Which area of the body should a nurse inspect for possible loss of skin integrity when
performing a skin examination on a female who is obese?
a) Under the breast
b) Upper abdomen
c) On the neck
d) Anterior chest - ️️Correct response: Under the breast
Explanation:
The nurse should inspec...
Health Assessment: Assessing Skin,
Hair, and Nails Chapter 13
Which area of the body should a nurse inspect for possible loss of skin integrity when
performing a skin examination on a female who is obese?
a) Under the breast
b) Upper abdomen
c) On the neck
d) Anterior chest - ✔️✔️Correct response: Under the breast
Explanation:
The nurse should inspect the area under the breast for skin integrity in obese clients.
The area between the skin folds is more prone to loss of skin integrity; therefore, the
presence of skin breakdown should be inspected on the skin on the limbs, under the
breasts, and in the groin area. Perspiration and friction often cause skin problems in
these areas in obese clients. The areas over the chest and abdomen and on the neck
are not prone to skin breakdown.
When assessing a client's terminal hair distribution, the nurse inspects all the following
areas except:
a) Limbs
b) Vertex
c) Palmar surfaces
d) Eyebrows - ✔️✔️Correct response: Palmar surfaces
Explanation:
The palms are one of the few areas not covered with hair, while the limbs, vertex, and
eyebrows all have terminal hair present.
A patient recovering from a burn injury is told by the health care provider that hair will no
longer grow on the body part that was burned. The nurse realizes that this patient's burn
extended into which skin layer?
a) Dermis
b) Distal phalanx
c) Epidermis
d) Subcutaneous tissue - ✔️✔️Correct response: Dermis
Explanation:
The skin has three layers. The epidermis is the outermost layer and is comprised of
dead keratinized cells and an inner layer that forms melanin and keratin. The dermis
, contains connective tissue and hair follicles. If the hair follicles are damaged by a burn,
hair will not regrow. The subcutaneous tissue layer of the skin continues fatty tissue.
The distal phalanx is a bone in the finger.
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to
describe which major characteristic of skin lesions?
a) Distribution
b) Colour
c) Arrangement
d) Type - ✔️✔️Correct response: Distribution
Explanation:
The given terms denote anatomic location, or distribution, of skin lesions over the body.
Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse
identifies that these could be what?
a) Herpes simplex
b) Varicella
c) Acne
d) Psoriasis - ✔️✔️Correct response: Acne
Explanation:
Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex
are vesicular lesions and psoriasis are plaque lesions
The RN should intervene and further educate the nursing assistant when observing
which action?
a) Assisting feeding a client ground chicken with dentures in place
b) Propping a client on the side using pillows under the hip, knees, and shoulder
c) Independently pulling an immobile client up in bed
d) Ambulating a client using a walker in the hallway - ✔️✔️Correct response:
Independently pulling an immobile client up in bed
Explanation:
Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a
client up in bed alone. The nursing assistant needs to ask for assistance when
repositioning an immobile client. Assisting with feeding or ambulating, and using pillows
under bony prominences to prevent pressure ulcers are all appropriate nursing assistant
tasks.
A nurse is instructing a client on how to assess himself for herpes simplex lesions by
their configuration. Which configuration should the nurse tell the client to look for?
a) Annular
b) Clustered
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