Integumentary Assessment Flashcards
Meet the Client: Mandi Majors
Mandi Majors, a high school senior, is an 18-year-old Caucasian with a history of previously treated bulimia nervosa. During a visit to the school clinic, Mandi tells the nurse that she vomited several times earlier that day.
The nurse is aware of Mandi’s history of bulimia and is concerned that she is at risk for nutritional and fluid volume deficits. Although Mandi is unwilling to undergo a full assessment, she allows the nurse to measure her vital signs and assess her skin, hair, nails, and mucus membranes.
After obtaining the client’s vital signs, the nurse assesses Mandi’s skin.
Info
Priority Data Collection 1. When assessing the skin of a client with bulimia, which data is important for the nurse to obtain? Thickness. Turgor. Texture. Pigmentation.
Turgor.
Assessment of skin turgor, or the degree of skin elasticity, provides data related to fluid volume balance.
The nurse assesses that Mandi’s skin turgor is slightly inelastic.
2. What additional finding validates the nurse's initial assessment regarding the client's fluid status? Areas of skin bruising. Rapid facial flushing. Dry mucus membranes. Shiny appearance of the forehead.
Dry mucus membranes.
Dry or cracked mucus membranes can be the result of inadequate hydration, which, like inelastic skin turgor, validates the initial finding of fluid volume deficit.
General Skin Assessment
Since entering the nurse’s office, Mandi’s face has become flushed, with flushing also noticeable bilaterally on her neck.
3.
The nurse observes that Mandi’s skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess?
Earlobes.
Hair follicles.
Cheeks and chin.
Conjunctivae.
Conjunctivae.
Because paleness of the skin can be difficult to detect in persons with dark or tanned skin, the membranes that line the eyelids (conjunctivae) are a good area to assess for pallor.
The nurse sees no evidence of pallor. 4. What follow-up assessment should the nurse perform after observing the facial flushing? Observe the color of the sclerae. Measure the oxygen saturation. Check for loss of skin integrity. Ask about any feelings of anxiety.
Ask about any feelings of anxiety.
Rapid facial and neck flushing are often the result of vasodilation secondary to stress or anxiety.
The nurse talks calmly with Mandi to help her relax while continuing the assessment.
5. The nurse observes that there are numerous blackheads around Mandi's chin and nose. What action should the nurse take in response to this finding? Note any pustules or nodules. Ask about a history of eczema. Measure for pitting edema. Palpate the areas for tenderness.
Note any pustules or nodules.
Blackheads are a form of acne, common in the adolescent when sebaceous gland activity increases. The nurse should look for signs of severe acne which may be manifested as pustules or nodules on other parts of the client’s body (such as the back or chest).
Client Interview
The nurse attempts to question Mandi about her vomiting. Mandi refuses to talk about the vomiting episodes that occurred earlier in the day, stating that she must have “eaten something bad” the night before for dinner. However, she seems open to talking about other things, so the nurse continues with the client interview, focusing on the appearance of her skin, hair, and nails.
6.
Which question is most important for the nurse to ask the client?
“Do you tend to bite or chew your nails?”
“What do you use to cleanse your skin?”
“How often do you use a tanning booth?”
“Do you use a hair coloring product?”
“How often do you use a tanning booth?”
Excessive use of a tanning booth increases the risk for skin cancer. Therefore, this is the most important question for the nurse to ask the client.
Mandi states that she goes to a tanning booth once or twice a month.
Skin Lesions
The nurse examines a mole on Mandi’s abdomen. The mole is oval, solid tan, and approximately 2 mm in diameter.
7.
The nurse questions Mandi about the observable moles on her skin. What question is most important to ask the client?
“Have you ever tried to cover up your moles with makeup?”
“Do the moles on your arms make you feel self conscious?”
“Do you have any moles on your abdomen or chest?”
“Have any of your moles changed in size or appearance?”
“Have any of your moles changed in size or appearance?”
Because a change in the size or appearance of a mole is a danger sign for skin cancer and warrants a referral for medical evaluation, this is the most important question for the nurse to ask.
In response to the nurse’s question, Mandi shrugs and tells the nurse that although she acknowledges the presence of moles on her body, she doesn’t pay much attention to them. She lifts her tee shirt to show the nurse her abdomen and back.
8.
What additional observation is important in assessing the mole?
The border of the mole is smooth.
The mole is surrounded by freckles.
There is no inflammation around the mole.
The mole does not blanche when compressed.
The border of the mole is smooth.
Border regularity is an important finding because border irregularity may be a cancer danger sign.
The nurse assures Mandi that there are no abnormal findings.
9.
Mandi also points out a small (1 mm), smooth, slightly raised bright red dot on her abdomen and asks the nurse to examine that spot as well. How should the nurse proceed?
Apply pressure over the lesion and observe for blanching.
Advise the client to be examined by a healthcare provider.
Offer assurance that this lesion is not an abnormal finding.
Determine if the client experienced any trauma at the site.
Offer assurance that this lesion is not an abnormal finding.
Cherry angiomas are commonly seen on the abdomen, particularly in persons over the age of 30. Angiomas typically increase in number and size with aging and are not a cause for concern.
Assessment of the Nails
After completing the assessment of Mandi’s skin lesions, the nurse takes Mandi’s hand and examines her fingernails.
10.
The nurse observes that the nail surface is slightly curved and the angle of the nail base is 160 degrees. What action should the nurse take in response to this finding?
Ask the client about any current or past use of cigarettes.
Continue the assessment, noting the color of the nail surface.
Use a pulse oximeter to measure the oxygen saturation.
Assess for crepitus underneath and around the nail surface.
Continue the assessment, noting the color of the nail surface. Correct
A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface.
11. While assessing the client's nails, it is most important for the nurse to follow-up on which assessment finding? Brittle nail surface. Ragged cuticles. Firm nail base. Irregular nail edges.
Brittle nail surface. Correct
Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client’s nutritional status.
Assessment of the Hair
Mandi has colored her hair solid black and uses an assortment of colored hair ties for accents. The nurse comments on Mandi’s hair color and proceeds to assess her hair.
12.
Which assessment is most important for the nurse to complete?
Ask the client how long she has colored her hair.
Check the client’s hair for split ends.
Observe the texture and distribution of hair growth on the scalp.
Note the pattern of hair growth around the client’s forehead.
Observe the texture and distribution of hair growth on the scalp.
Dull, dry, sparse hair may be the result of a nutrient deficiency, such as insufficient protein or zinc. These findings would support the nurse’s concerns regarding Mandi’s overall nutritional status.
13.
Mandi tells the nurse that her scalp itches sometimes. The nurse observes white flecks on the client’s shoulders. What action should the nurse take first?
Instruct the client about dandruff treatments.
Observe the client’s hair shafts and scalp.
Remind the client not to share hairbrushes.
Explain how to treat the hair and scalp for head lice.
Observe the client’s hair shafts and scalp.
Loose white flecks typically indicate dandruff. However, since itching may also be the result of head lice, the nurse should observe the scalp and hair shafts for the presence of nits, which adhere to the hair shaft.
Further assessment does not reveal the presence of any head lice or nits.
14.
The nurse observes the overall hair distribution on Mandi’s face and arms. There is visible hair growth on her forearms. She has thin eyelashes and eyebrows, and otherwise fine, downy facial hair. What action should the nurse take in response to these observations?
Ask the client if the excessive hair growth on her arms is of concern to her.
Note the absence of normal hair growth patterns on the client’s face.
Document the areas of alopecia as an indication of the client’s poor nutrition.
Move on to the next area of assessment since the findings are within normal limits.
Move on to the next area of assessment since the findings are within normal limits.
The findings are within normal limits, so the nurse should continue the assessment.
