NURSING HEALTH ASSESSMENT Chapter 60 assessment of integumentary function Exam

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? "Have you been in the sun a lot?" "Have you been eating a large amount of carotene-rich foods?" "Have you been diagnosed with Addison's disease?" "Have you been ingesting large quantities of alcohol?" "Have you been eating a large amount of carotene-rich foods?" Explanation: The patient is demonstrating signs of carotenemia, a condition resulting in a yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes, and resulting from an increased level of serum carotene from ingestion of large amounts of carotene-rich foods. A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? Jaundice Bronzed appearance Pallor Cherry red face Jaundice Explanation: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin (2-3 mg/100 mL) and is often first observed in the sclerae and mucous membranes. The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? Psoriasis Vitiligo Melanoma Petechia Psoriasis Explanation: Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea. The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply. Evaluate the client's level of pain, using a numeric value pain scale. Palpate the client's skin for moisture, temperature, and texture. Ask the client whether the wound bed or surrounding skin itches. Review the client's prothrombin time test and international normalized ratio. Measure and assess the client's wound bed, size, edges, and margins. Evaluate the client's level of pain, using a numeric value pain scale. Ask the client whether the wound bed or surrounding skin itches. Palpate the client's skin for moisture, temperature, and texture. Measure and assess the client's wound bed, size, edges, and margins. Explanation: If wounds are found on inspection of the skin, a comprehensive assessment should be made and documented. The assessment should include the wound size and measurement to determine the diameter and depth of the wound and surrounding erythema. The wound bed should be inspected for necrotic and granulation tissue, epithelium, exudate, color, and odor. The surrounding skin should be assessed for color, suppleness, itching and scaling. The edges and margins should be assessed for