HESI Case Study Integument Assessment – Flashcards

1. When assessing the skin of a client with bulimia, which data is important for the nurse to obtain? -Texture -Pigmentation -Turgor -Thickness

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 -Dry Mucus membranes -Shiny appearance of the forehead -Rapid Facial flushing

Because Mandi shows early signs of fluid volume deficit, the nurse provides her with a sports drink. While Mandi drinks the fluid, the nurse continues the 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 are should the nurse assess? -Cheeks and chin -Earlobes -Hair follicles -Conjuctivae

The nurse sees no evidence of pallor. 4. What follow up assessment should the nurse perform after observing the facial flushing? -Ask about any feelings of anxiety -Observe the color of the sclerae -Measure the oxygen saturation -Check for loss of skin integrity

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 -Palpate the areas for tenderness -Ask about a history of eczema -measure for pitting edema

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? -"How often do you use a tanning booth?" -"Do you use a hair coloring product?" -"What do you use to cleanse your skin?" -"Do you tend to bite or chew your nails?"

The nurse examines a mole on Mandi's abdomen. The mole is oval, solid tan, and approximately 2mm in diameter. 7. The nurse questions Mandi about the observable moles on her skin. What question is most important to ask the client? -"Have any of your moles changed in size or appearance?" -"Do you have any moles on your abdomen or chest?" -"Do the moles on your arms make you feel self-conscious?" -"Have you ever tried to cover up your moles with make up?"

8. What additional observation is important in assessing the mole? -There is no inflammation around the mole -The mole is surrounded by freckles -The mole does not blanche when compressed -The border of the mole is smooth

9. Mandi also points out a small (1mm), smooth, slightly raised bright red dot on her abdomen and asks the nurse to examine the spot as well. How should the nurse proceed? -Offer assurance that this lesion is not an abnormal finding -Apply pressure over the lesion and observe for blanching -Advise the client to be examined by a healthcare provider -Determine if the client experience any trauma at the site

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 degree. What action should the nurse take in response to this finding? -Use a pulse oximeter to measure the oxygen saturation -Ask the Client about any current or past use of cigarettes -Continue the assessment, noting the color of the nail surface -Assess for crepitus underneath and around the nail surface

11. While assessing the Client's nails, it is most important for the nurse to follow-up on which assessment finding? -Ragged cuticles -Firm nail base -Irregular nail edges -brittle nail surface

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 -Observe the texture and distribution of hair growth on the scalp -Check the client's hair for split ends -Note the pattern of hair growth around the client's forehead

12. Mandi tells the nurse that her scalp itches sometimes. The nurse observes while flecks on the client's shoulders. What action should the nurse take first? -Instruct the client about dandruff treatments -Explain how to treat the hair and scalp for head lice. -Remind the client not to share hair brushes -Observe the client's hair shafts and scalp

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? -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 -Note the absence of normal hair growth patterns on the client's face. -Ask the client if the excessive hair growth on her arms is of concern to her

While observing the mole and cherry angioma on Mandi's abdomen, the nurse also observed several areas of apparent skin injury on Mandi's lower abdomen. Because the nurse feels a trusting relationship has now been established, the nurse believes that Mandi may respond to further assessment related to the injured areas and asks Mandi to allow the nurse to observe her abdomen again. Mandi agrees. 15. The nurse observes several bruises of various colors across Mandi's lower abdomen. What concern should the nurse address? -Painful injury with hot and cold objects -Recent injury with different sized objects -Repeated injury over a period of time -Self-inflicted injury to obtain attention

16. 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 -Ask the client how these burns occurred -Palpate the areas for warmth and swelling -immediately measure and record the vital signs

17. After expressing concern about the bruises on Mandi's abdomen, how should the nurse begin the abuse assessment? -Determine if the client is sexually active. -Ask the client if someone else caused the injuries -Encourage the client to describe her family structure -Advise the client of her right to legal counsel during the interview

18. To gather data related to the frequency of abuse by Mandi's boyfriend, what action should the nurse take first? -Determine if the client has ever tried to break up with her boyfriend and how she attempted to the end the relationship -Provide a calendar for the client to mark the dates when any violent and abusive behavior by her boyfriend occurred. -Instruct the client that there is no point in denying the pattern of abuse because of the varying colors of the bruises -Ask the client about her boyfriend's use of any illegal drugs or frequency of alcohol abuse since they have been dating

While conversing with the nurse about her boyfriend, Mandi starts to scratch her neck, and says "On no, this happens sometimes when I get really stressed." 19. What finding should the nurse expected in response to Mandi's itching? -Hirsutism -Urticaria -Purpura -Pustules

20. The nurse observes raised, pink wheals on Mandi's neck. How should the nurse respond to this observation? -Apply a warm compress directly over the wheals -Offer assurance that this is a temporary response -Ask if the client has been stung by an insect recently -Explain that antibiotics will need to be prescribed

21. The nurse prepares to administer diphenhydramine (Benadryl) 12.5mg orally. The tablet is supplied in a 25mg doe. How many tablet(s) should the nurse give?_________ (enter numerical value only)

The nurse teaches Mandi about Benadryl. Which information should the nurse included? (select all that apply.) -Blurred vision or loss of balance are potentially serious side effects of this medication -This medication may cause an increase in secretions and moisten mucous membranes. -This medication may cause drowsiness. -Benadryl blocks the effect of histamine response to reduce itching -Benadryl products contain aspirin, so observe for signs of bleeding

Before reporting the information obtained about the physical abuse that Mandi experienced, the nurse documents the findings. 23. Which strategy should the nurse use to document the extent of the physical injuries? -Include xrays in the client record -use the numeric braden scale -prepare a detailed injury map -complete the abuse assessment screen

How should the nurse document the information obtained when charting Mandi's abuse assessment? -Refrain from including information that might identify the alleged abuser. -Summarize the abusive events without directly quoting the client -Delete any expletives the client used when describing the abuser -Quote the client's responses to the questions as verbatim as possible