Upgrade to remove ads
HESI 1 Integumentary Assessment
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
HESI 1 Integumentary Assessment
Terms in this set (27)
Q1) The nurse interviews the 17 year old client for subjective data regarding the itching. The nurse questions the client about her symptoms. What should the nurse ask about first?
Severity and Location of the Itching (This is the priority question. Itching may be a symptom of a more life threatening problem and the severity needs to be assessed as a priority). Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p.200). St. Louis, MO: Elsevier
Q2) The client states she feels like something is crawling on her skin all over her body. The nurse questions the client about anaphylaxis. What client cues would indicate the the presence of an anaphylactic reaction?
1) Drooling (Drooling is a symptom of a closing airway in an adult client. Closing of the airway may occur during anaphylaxis.) 2) Shortness of breath (Shortness or breath or wheezing may be present if the airway is compromised due to anaphylaxis.) 3) Flushed or Pale Skin (Skin may be flushed or pale related to the reaction.)
The client denies difficulty swallowing, shortness of breath, nausea, or dizziness. No centralized pallor or flushing is noted. The nurse determines that the client is not having a anaphylactic reaction. The nurse will continue to monitor the client for changes in condition. The nurse completes the client interview. The client denies history of skin conditions, rashes, new medications or changes in toiletry or laundry items. The nurse completes the initial client interview and determines the client is in need of diphenhydramine to reduce the effects of the itching. The chart notes parental consent of prn Diphenhydramine
Q3) The nurse prepares to administer diphenhydramine 50 mg orally. The tablet is supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value only. If rounding is necessary, round to the tenth.)
Q4) The nurse teaches the client about diphenhydramine. Which information should the nurse include? (Select all that apply. One, some, or all options may be correct.)
1) Diphenhydramine blocks the effect of the histamine response to reduce itching (Diphenhydramine is a H1 receptor antagonist and may be helpful to reduce itching associated with hives). 2) Diphenhydramine products contain aspirin, so observe for signs of bleeding (All diphenhydramine products are aspirin free and bleeding is not a side effect). 3) This medication may cause drowsiness (Although considered a minor side effect, diphenhydramine may cause drowsiness).
Q5) After confirming that the client is not allergic to diphenhydramine, the nurse administers the client an over the counter diphenhydramine. The nurse continues an assessment of the client. The nurse will monitor the effects of the diphenhydramine on the client's allergic reaction. The nurse begins her assessment of the integumentary system. Place the items in the order that the nurse should perform the techniques for physical examination of the integumentary system.
Inspection, Palpation, Percussion, and Auscultation (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 124). St. Louis, MO: Elsevier.)
Q6) The nurse observes that the client's skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess?
Conjunctivae (eyelids) (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). (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 206). St. Louis, MO: Elsevier.)
Q7) What action should the nurse perform if rapid facial flushing is observed?
Ask about any feelings of anxiety (Rapid facial and neck flushing are often the result of vasodilation secondary to stress or anxiety.) (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 204). St. Louis, MO: Elsevier.)
Q8) The nurse observes that there are numerous blackheads around client's chin and nose. What action should the nurse take in response to this finding?
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).
Q9) What health promotion question is most important for the nurse to ask the client?
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. The client states that she goes to a tanning booth once or twice a month.)
Q10) The nurse assesses that the client's skin turgor is slightly inelastic. The nurse suspects that the client is fluid volume deficient. What cues support the nurse's assessment regarding the client's fluid status?
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). (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 208). St. Louis, MO: Elsevier.)
Q11) The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask? (Select all that apply. One, some, or all options may be correct.)
1) Have you experienced nausea or vomiting recently? (Vomiting can cause loss of fluid resulting in fluid volume deficit). 2) How much water are you drinking per day? (Inadequate intake of fluids especially water may result in fluid volume deficit.) 3) Have you experienced diarrhea recently? (Diarrhea can cause loss of fluid resulting in fluid volume deficit.)
Q12) The nurse examines a mole on the client's abdomen. The mole is oval, solid tan, and approximately 2 mm in diameter.
Have any of your moles changed in size of 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). (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 208). St. Louis, MO: Elsevier.)
Q13) What additional observation is important in assessing the mole?
The border of the mole is smooth (Border regularity is an important finding because border irregularity may be a cancer danger sign). (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 208). St. Louis, MO: Elsevier.)
Q14) The client points out a small (1 mm), smooth, slightly raised bright red dot located on the abdomen. The client asks the nurse to examine that spot as well. How should the nurse proceed?
Offer assurance that this 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.).
Q15) The nurse completes the assessment of the client's skin lesions. The nurse begins to examine the client's fingernails. 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?
Continue the assessment noting the color of the nail surface (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). (Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. (p. 211). St. Louis, MO: Elsevier)
Q16) While assessing the client's nails, it is most important for the nurse to follow-up on which assessment finding?
Brittle nail surface (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.).
Q17) The nurse proceeds to assessment of the client's hair. The nurse questions the client about use of hair dye. The client confirms the use of hair dye. Which assessment is most important for the nurse to complete?
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 the client's overall nutritional status).
Q18) The client states, "My scalp itches sometimes." What action should the nurse take first?
Observe the client's hair shafts and scalp (Loose white flecks may indicate dandruff. 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.). (Jarvis, pg .210)
Q19) The nurse observes the overall hair distribution on the client's face and body. There is visible hair growth on the forearms but no visible hair on the lower extremities. The client has thin eyelashes and eyebrows, and fine, downy facial hair. What action should the nurse take in response to these observations?
Move onto the next area of assessment since the findings are within normal limits
Q20) While observing the mole and cherry angioma on the client's abdomen earlier, the nurse also observed several areas of apparent skin injury on the client's lower abdomen. Because the nurse feels a trusting relationship has now been established, the nurse believes that the client may allow further assessment of the injured areas. The nurse asks the client about observing the abdomen again. The client agrees. The nurse observes several bruises of various colors across the client's lower abdomen. How should the nurse interpret this assessment finding?
Repeated injury over a period of time (New bruises are generally red in color and change color over time. Bruises typically progress from purple-blue to blue-green to green-brown and finally to a brownish-yellow color before disappearing.).
Q21) The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?
Document the location of the bruises and petechiae (Petechiae are very small areas of hemorrhage from superficial capillaries. They may be the result of a bleeding or clotting problem as well as an indication of superficial trauma. The presence of bruising and petechiae on the client's abdomen causes the nurse to suspect that the client may be the victim of abuse).
Q22) The nurse expresses concern regarding the client's bruise. What action should the nurse take to initiate the abuse assessment?
Ask the client if someone else caused the injuries (It is appropriate to first ask a direct question to elicit information about possible abuse. If the client is reluctant to respond to a direct question about possible abuse, the nurse may then choose to use an indirect approach to encourage further verbalization). (Jarvis, pg 102)
Q23) The client tells the nurse that the client's partner is 21-years-old. The couple have been involved together for 6 months. After they go out to eat, the client's partner complains that the client is fat and sometimes punches the client in the stomach so that the client will throw up dinner and remember to eat less the next time.
Provide a calendar for the client to mark the dates when any violent or abusive behavior by the client's partner occurred (A calendar is a useful visual aid in that it can help the client "see" the frequency of the abuse, and it can help the nurse determine if there is an escalation of violence toward the client. This is the first step when implementing a danger assessment for the client. The client may also be requested to complete a scale of violence to help the nurse assess the magnitude of the abuse).
Q24) What finding should the nurse expect in response to the client's itching?
Urticaria (Urticaria, or hives, are highly pruritic(itchy) and can appear in response to many stimuli, including emotional stress.) Hives is a common skin rash triggered by many things including certain foods, medications, and stress (in this case stress). Symptoms include itchy, raised, red, or skin-colored welts on the skin's surface.
Q25) The nurse observes raised, pink wheals on the client's neck. How should the nurse respond to this observation?
Offer assurance that this is a temporary response (Urticaria, or hives, is an inflammatory response that is generally transient).
Q26) Before reporting the information obtained about the physical abuse that the experienced, the nurse documents the findings. How should the nurse document the information obtained when charting the client's abuse assessment?
Quote the client's responses to the questions as verbatim as possible (Documentation should be as verbatim as possible to provide the most detailed, accurate information).
Other sets by this creator
HESI 5 Constipation
HESI 4 Urinary Patterns
Vital Signs Ch 10
Other Quizlet sets
akin -- semester 2 final (background)
Biology AS-LEVEL AQA 2017
Psych SAC revision