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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.
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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 plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client's plan of care? (Select all that apply.)
- A. Height
- B. Allergies
- C. Alcohol use
- D. Prealbumin laboratory results
- E. Liver enzyme laboratory results
Correct Answer: A,C,D
Rationale: Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. Assessing height, alcohol use, and prealbumin laboratory results will provide information related to vitamin and protein deficiencies and obesity. Allergies and liver enzyme results will not provide information about nutritional status or wound healing.
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 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 an older adult's skin. Which findings require immediate referral? (Select all that apply.)
- A. Excessive moisture under skin folds
- B. Increased hair thinning
- C. Increased presence of fungal toenails
- D. Lesion with various colors
- E. Spider veins on legs
- F. Asymmetric 6-mm dark lesion on forehead
Correct Answer: D,F
Rationale: Skin lesions with various colors and an asymmetric 6-mm dark lesion fit two of the American Cancer Society's hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.