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A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?
- A. Clean hair, skin, and nails
- B. Poor eye contact
- C. Disheveled appearance
- D. Drapes a scarf over the face
Correct Answer: A
Rationale: The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails, good eye contact, and being socially active. A disheveled appearance and draping a scarf over the face to hide the client's appearance demonstrate that the client may not be coping effectively.
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A nurse assesses an older adult client with a skin disorder shown in the image. How should the nurse document this finding?
- A. Petechiae
- B. Ecchymoses
- C. Actinic lentigo
- D. Senile angiomas
Correct Answer: A
Rationale: Petechiae are small, reddish-purple, non-raised lesions that do not fade or blanch with pressure. Ecchymoses are larger areas of hemorrhaging (bruising), actinic lentigo presents as paper-thin, transparent skin, and senile angiomas are red, raised lesions.
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a dime and has irregular borders. How should the nurse document this finding?
- A. Annular
- B. Diffuse
- C. Clustered
- D. Linear
Correct Answer: B
Rationale: Diffuse is used to describe lesions that are widespread. The description of two lesions with irregular borders does not fit annular (circular), clustered (grouped together), or linear (in a straight line).
A nurse assesses a client who has open lesions. Which action should the nurse take first?
- A. Put on gloves.
- B. Ask the client about his or her occupation.
- C. Assess the clients pain.
- D. Obtain vital signs.
Correct Answer: A
Rationale: Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients 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 area 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.
Correct Answer: C
Rationale: Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. Using powder to keep the area dry is an appropriate measure to manage this condition.
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should 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?
Correct Answer: D
Rationale: 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.