Nokea
The nurse is performing a skin assessment on a client who points out a small, round, flat area of skin that is a different color than the surrounding tissue. What term should the nurse use to document this finding?
- A. Macule
- B. Papule
- C. Vesicle
- D. Wheal
Correct Answer: A
Rationale: The nurse should document this finding as a macule, which describes a flat, round, and colored area of skin. A papule is solid and has an elevated, obvious raised border. A vesicle is elevated, round, and filled with serum. A wheal is elevated, has an irregular border, and contains no free fluid.
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A female client comes to the clinic and tells the nurse, 'I am getting all these little hairs on my chin. I never had them before I turned 50.' What does the nurse understand is the cause of the terminal hairs on the face?
- A. Overproduction of melanin
- B. Increased secretion of sebum
- C. Decline in the number of eccrine glands
- D. Decreased ratio of estrogen to androgen hormones
Correct Answer: D
Rationale: After menopause, some women develop sparse terminal hairs about their face as the ratio of estrogen to androgen hormones decreases. An overproduction of melanin would cause altered color of the skin. Increased secretion of sebum is an oily substance that may cause blackheads and pustules. A decline in the number of eccrine glands will cause a decrease in perspiration in the older adult.
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
Plantar warts may be treated with what method?
- A. Photochemotherapy
- B. Radiation
- C. Electrodesiccation
- D. Cryosurgery
Correct Answer: C
Rationale: Electrodesiccation is the use of electrical energy converted to heat, which destroys the tissue. Photochemotherapy involves a combination of psoralen methoxsalen and type A ultraviolet light. Radiation therapy is used to treat malignant skin lesions. Cryosurgery is the application of extreme cold to destroy tissue.
A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?
- A. Calluses
- B. Senile keratosis
- C. Senile lentigines
- D. Rheumatoid nodules
Correct Answer: A
Rationale: Areas of skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin. Senile keratosis is small, yellow or brown raised lesions that appear on the face and trunk in an older adult client. Senile lentigines are also known as liver spots and are found on the hands and forearms of older people. Rheumatoid nodules affect those clients with rheumatoid arthritis.
Which of the following pigments influences hair color?
- A. Pheromones
- B. Keratin
- C. Seburin
- D. Melanin
Correct Answer: D
Rationale: Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Seburin is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.