26

Chapter 26: Assessment of the Skin, Hair, and Nails
Test Bank
MULTIPLE CHOICE
1. The nurse is planning care for an older client who has very thin skin on the backs of the hands
and arms. What is the clients priority problem?

Risk for injury
Infection
Poor self-image
Discomfort
a.
b.
c.
d.
ANS: A
Thinning skin, with decreased attachment between the dermis and the epidermis, is at
increased risk for injury in response to even minimal trauma or shearing events. If injury
occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor
self-image does not take priority over the risk for injury.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Planning)
2. A client has a suspected superficial fungal infection. The nurse prepares the client for a culture
by explaining the procedure. Which statement by the client indicates a correct understanding
of the procedure?
a. The doctor will shave off a small piece of the lesion.
b. You will be performing what is called a punch biopsy.
c. A sample is obtained by simply scraping the lesion.
d. Youll squeeze material from the lesion to send to the laboratory.
ANS: C
A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade. The
other techniques are not used for a suspected superficial fungal infection.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests)
MSC:
Integrated Process: Teaching/Learning
3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation,
what is the nurses best action?

Evaluate the client further for hepatitis.
Examine the soles of the clients feet.
Inspect the clients oral mucosa.
Place the client in contact isolation.
a.
b.
c.
d.
ANS: C
The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa,
especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat
deposits that show a yellow hue. Before considering hepatitis, the nurse must do a more
thorough assessment. The soles of the feet may appear yellow simply from calluses, so this is
not the best place to assess. No need to isolate the client has been identified.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical
Assessment)
MSC: Integrated Process: Nursing Process (Assessment)
4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment
data, what does the nurse do next?

Take a medication history.
Assess pulse oximetry.
Assess the clients personal hygiene.
Palpate the soles and palms.
a.
b.
c.
d.
ANS: B
Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin,
cyanosis can be seen because the palms, soles, and conjunctivae have a bluish tinge. The nurse
should assess for systemic oxygenation before continuing with other assessments.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific
Assessments)
5. An older client with age spots is fearful of contracting skin cancer but wants to continue his
hobby of outdoor gardening. Which statement by the client indicates a good understanding of
the teaching about this issue?
a. I will avoid staying outside during the day.
b. I can use only oil-based tanning lotion.
c. I have to start growing plants indoors.
d. I will wear a hat and gloves when gardening.
ANS: D
Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin
protects against the harmful effects of sun exposure. Hyperpigmentation can occur in sunexposed areas and can lead to skin cancer. For clients who spend time outdoors, the best
protection from skin cancer is decreasing the amount of skin exposed to sunlight.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
6. An older client expresses concern about developing new age spots. Which instruction is
most important for the nurse to provide to the client?

Limit the time you spend in the sun.
Monitor for signs of infection.
Monitor spots for color change.
Use skin creams to prevent drying.
a.
b.
c.
d.
ANS: C
The ABCDE method (check for asymmetry, border irregularity, color variation, diameter, and
evolving [changing] in any feature) should be used to assess lesions for signs associated with
cancer. Any positive finding using this method requires the lesion to be examined by a
dermatologist or a surgeon. The other options are good instructions for clients too, but this
client is worried about lesions that are already present.
REF: N/A
MSC: Integrated Process: Nursing Process (Implementation)
7. A client is seen in the clinic for a persistent hand rash. When taking the clients history, the
nurse places priority on obtaining information related to which topic?

Age
Gender
Occupation and hobbies
Socioeconomic status
a.
b.
c.
d.
ANS: C
The location of the rash suggests contact dermatitis. This condition is most often caused by
contact with irritating substances such as might be found in industrial settings or associated
with specific hobbies. Socioeconomic status may be related to the rash, particularly if it is
associated with poor hygiene, but age and gender are not related to rashes.
REF: N/A
Assessments)
8. A client is admitted with inflamed soft tissue folds around his nail plates. Which question by
the nurse elicits the most useful information about the possible condition?
a. What do you do for a living?
b. Do you keep your nails manicured?
c. Do you have diabetes?
d. Have you had any fungal nail infections?
ANS: A
The condition, chronic paronychia, is common in people with frequent intermittent exposure
to water, such as homemakers, bartenders, and laundry workers.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
9. A client has multiple bruises on the arms. Which question provides the nurse with the most
information?
Are you using lotion on your skin?
Do you have a family history of this?
Do your arms itch?
What medication are you taking?
a.
b.
c.
d.
ANS: D
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Side Effects/Interactions)
10. A client had an excisional biopsy on a neck lesion. Which information does the nurse include
in the discharge instructions?

Stay in bed today to prevent excessive bleeding from the incision.
Do not drive until you have recovered from the anesthesia.
You will need to change the dressing daily for a week.
Keep the dressing on until tomorrow, then you may remove it.
a.
b.
c.
d.
ANS: D
This client has no reason to avoid going about normal activities as long as the site stays
covered for a day with a dressing. Movement should not cause excessive bleeding, and
general anesthesia would not have been used.
REF: N/A
11. A client asks the nurse if a Woods light examination is painful. Which response by the nurse
is accurate?
A local anesthetic will be used to prevent pain.
The pain lasts only a few seconds.
Some clients feel a pressure-like sensation.
The examination does not cause discomfort.
a.
b.
c.
d.
ANS: D
The Woods light examination consists of use of a black light and a darkened room to assist
with physical examination of the skin. The examination does not cause discomfort.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 468
Assessments)
12. A client expresses concern about a rash located beneath her breast. What statement by the
client indicates a good understanding of this condition?

This rash is probably due to fluid overload.
I need to wash this daily with antibacterial soap.
I can use powder to keep this area dry.
I will schedule a mammogram as soon as I can.
a.
b.
c.
d.
ANS: C
Rashes limited to skin-fold areas (e.g., on the axillae, beneath the breasts, in the groin) may
reflect problems related to excessive moisture. The client needs to keep the area dry; one
option is to use powder. Good hygiene is important, but the rash does not need an antibacterial
soap. The other two options are not related to rashes in skin folds.

REF: N/A
13. A client comes to the clinic reporting pain and itching from blisters on both arms. This finding
indicates an abnormality in which layer of the skin?

Adipose tissue
Dermis
Epidermis
Stratum corneum
a.
b.
c.
d.
ANS: B
The dermis or dermal layer of the skin contains sensory nerves that transmit sensations of
touch, pressure, temperature, pain, and itch.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 453
14. A client has two skin lesions, each the size of a nickel, on his chest. Both lesions are flat and
are a darker color than the rest of the clients skin. How does the nurse document this finding?
Two 2-cm hyperpigmented patches
Two 1-inch erythematous plaques
Two 2-mm pigmented papules
Two 1-inch moles
a.
b.
c.
d.
ANS: A
Patches are larger flat areas of the skin. The information provided does not indicate a mole or
the presence of erythema.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 460
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
15. The nurse reads in the chart that a client has a fine, macular rash on the lower extremities. The
nurse inspects the clients skin, looking for lesions that can be described with which term?
Flat
Raised
Rough
Blood-filled
a.
b.
c.
d.
ANS: A
A rash that is flat is described as macular. The other descriptions are not accurate.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 463
Systems)
16. On assessing a clients lower extremities, the nurse notices that one leg is pale and cooler to
the touch. Which assessment does the nurse perform next?

a. Ask about a family history of skin disorders.
b. Palpate the clients pedal pulses bilaterally.

c. Check for the presence of Homans sign.
d. Assess the clients skin for adequate skin turgor.
ANS: B
Localized, decreased skin temperature and pallor indicate interference with vascular flow to
the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency.
Without adequate blood flow, the clients limb could be threatened. Asking about a family
history of skin problems would not take priority over assessing blood flow. Homans sign is a
screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information
about hydration status. This assessment may be needed but certainly does not take priority
over assessing for blood flow.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
MSC:
Integrated Process: Nursing Process (Assessment)
17. The nurse observes hirsutism in a female client. What does the nurse do next?
a. Assess for deepening of the voice.
b. Assess personal hygiene habits.
c. Document the finding.
d. Prepare the client for a biopsy.
ANS: A
Increased hair growth on the face and chest of a female client (hirsutism) is one manifestation
of hormonal imbalance. The nurse looks for additional associated changes in fat distribution
and capillary fragility (Cushings syndrome) or clitoral enlargement and deepening of the
voice (possible ovarian dysfunction). The other options are not related to this condition.
REF: N/A
Systems)
MULTIPLE RESPONSE
1. The nurse is assessing for skin changes in an older woman. Which findings require immediate
referral? (Select all that apply.)

Excessive moisture under axilla
Increased hair thinning
Increased presence of fungal toenails
Lesion with various colors
Spider veins on legs
Asymmetric 6-mm dark lesion on forehead
a.
b.
c.
d.
e.
f.
ANS: D, F
The asymmetric 6-mm dark lesion, as well as the lesion with various colors, fits two of the
American Cancer Societys hallmark signs for cancer according to the ABCD method. Other
manifestations are variants of normal seen in various age-groups.
REF: N/A
Systems)
MSC: Integrated Process: Nursing Process (Implementation)

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Chapter 26: Assessment of the Skin, Hair, and Nails

and arms. What is the clients priority problem?

what is the nurses best action?

data, what does the nurse do next?

most important for the nurse to provide to the client?

nurse places priority on obtaining information related to which topic?

in the discharge instructions?

client indicates a good understanding of this condition?

DIF: Cognitive Level: Application/Applying or higher

indicates an abnormality in which layer of the skin?

the touch. Which assessment does the nurse perform next?

b. Palpate the clients pedal pulses bilaterally.

referral? (Select all that apply.)

MSC: Integrated Process: Nursing Process (Implementation)

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