Nokea
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.
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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.
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.
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.
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 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.