hesi rn case study integumentary assessment

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Nurs 125- Health Assessment I > HESI Case Study- Integumentary Assess + Neuro > Flashcards

HESI Case Study- Integumentary Assess + Neuro Flashcards

The nurse interviews the 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.

The nurse questions the client about anaphylaxis. What client cues would indicate the presence of an anaphylactic reaction?

drooling shortness of breath flush/pale skin

The nurse begins her assessment of the integumentary system. Select the techniques the nurse should perform.

Palpation. The nurse should inspect and palpate the skin and appendages, such as hair and nails, as well as the mucous membranes.

Inspection. The nurse should inspect and palpate the skin and appendages, such as hair and nails, as well as the mucous membranes.

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.

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.

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.

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).

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.

The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask?

Have you experienced nausea or vomiting recently?” Vomiting can cause loss of fluid, resulting in fluid volume deficit.

“How much water are you drinking per day?” Inadaquate intake of fluids, especially water, may result in fluid volume deficit.

“Have you experienced diarrhea recently?” Diarrhea can cause loss of fluid resulting in fluid volume deficit.

The nurse examines a mole on the client’s abdomen. The mole is oval, solid tan, and approximately 2 mm in diameter. The nurse observes multiple moles on the client’s skin. What question is most important to ask the client?

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.

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 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.

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.

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.

Traumatized nail folds.

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.

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.

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.

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 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.

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 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.

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.

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.

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. To gather data related to the pattern of abuse, what action should the nurse take first?

Provide a calendar for the client to mark the dates when any violent and 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.

While conversing with the nurse about the situation, the client starts to scratch and says, “Oh no, this happens sometimes when I get really stressed.” What finding should the nurse expect in response to the client’s itching?

Urticaria. Urticaria, or hives, are highly pruritic and can appear in response to many stimuli, including emotional stress.

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

Before reporting the information obtained about the physical abuse, 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.

When eliciting data about possible neurological problems, what information should the nurse obtain from the client?

Any difficulty speaking or swallowing. Headache frequency and location. Any numbness,tingling, or weakness of extremities. Did the head hit the floor with syncopal episode.

Based on the client’s recent history of loss of consciousness and falling, what additional assessment takes priority?

Blood pressure and heart rate and rhythm.

Hypotension and bradycardia can cause a loss of consciousness. Bradycardia may also be a sign of increased intracranial pressure.If the client has hypertension, it places the client at increased risk for a hemorrhagic stroke. If the client has cardiac irregularity, such as atrial fibrillation, the client should be evaluated and treated to prevent an embolic stroke.

To determine what happened to the client prior to the loss of consciousness, the nurse should obtain what information from the client? (Select all that apply. One, some, or all options may be correct.)

Select all that apply

Ask the client to stick out their tongue.

Ask the client if they ever feel lightheaded or dizzy.

Ask the client if they have any problems with smell.

Ask the client if the dizziness occurs when they change positions.

Ask the client if they felt like the room was suddenly spinning before the fell.

During the interview, the nurse observes the client’s speech patterns. The client seems to have difficulty choosing and forming some words. What action should the nurse take?

Affirm the client’s difficulty and ask about when this first started.

Fill in the conversation with the words the client is attempting to say.

Offer to complete the interview at a later time after the client has rested.

Allow the client to respond and ignore any difficulty to avoid embarrassment.

This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client’s symptoms.

Before continuing the interview and assessment, the nurse enters the following initial data collected into a tablet: The client demonstrates difficulty speaking and previously reported feeling weak, passing out, and falling at home. Vital signs are currently T 97° F (36o C), Blood Pressure 140/88 mmHg, heart rate 92beats/min, and respirations 18 breaths/min.

What terminology should be included in the nurse’s documentation?

Tachycardia.

Syncope is a sudden loss of strength or temporary loss of consciousness, which the client described as “passing out.”

In documenting the client’s difficulty speaking, the nurse recalls that the client had difficulty forming some words and phrases. Before describing this finding on the assessment form, what additional data should the nurse consider?

How many words per minute the client is able to speak.

The client’s ability to comprehend what is being asked.

If any mouth drooping is observed when the client spoke.

Whether the client is able to read the nurse’s lips accurately.

Aphasia should be assessed to determine if the client has lost the ability to comprehend information (receptive aphasia) or the ability to express herself (expressive aphasia). Most commonly, the client experiences both, referred to as global aphasia.

While continuing the interview, the nurse assesses the client’s mental status. As the interview continues, the client occasionally struggles to choose and form words, but seems comfortable and relaxed. The nurse provides a quiet, calm environment, allowing ample time to respond to the interview questions. The client asks the nurse what the room number is, stating the need to let family know.

Which assessment by the nurse accurately reflects the client’s statement?

Disoriented to place.

Oriented to situation.

Loss of recent memory.

Loss of immediate memory.

The client’s statement describing the need to notify family that the client is in the hospital indicates an orientation to situation. Lack of knowledge of room number does not reflect disorientation or memory loss.

To assess the client’s recent memory more completely, what action should the nurse take?

Encourage reminiscing about the birth of a child.

Question how the client arrived at the hospital today.

List four words and ask the client to repeat them back.

Observe the client’s cooperation in answering interview questions.

This action provides information related to the client’s recent memory. The nurse should ask questions with verifiable answers to ensure the client does not make up responses.

Which interview data provides the nurse with information related to the client’s judgment?

Reminiscing about the birth of a child caused the client to cry gently.

The client indicated the need to notify family about being in the hospital.

Repeating back a list of four words made the client anxious and uncomfortable.

The client was cooperative but vague in describing how the neighbor found her.

The client’s recognition of the need to notify family of being in the hospital is an indication of good judgment.

After completing the interview and mental status exam, the nurse tests the client’s cranial nerves to determine if there is a deficit.

The nurse observes the client moving through the six cardinal fields of gaze by following an object or fingers without the head moving. Which cranial nerves are tested when the nurse is evaluating the client’s extra ocular movements? Select all that apply

Optic (CN II).

Facial (CN VII).

Trochlear (CN IV).

Trigeminal (CN V).

Abducens (CN VI).

Oculomotor (CN III).

Trochlear (CN IV). Oculomotor (CN III). Abducens (CN VI).

Optic (CN II) Optic measures __________________________ vision.

central and peripheral

_________ CN VII: measures pain and temperature from ear area; deep sensations from the face; taste from anterior two thirds of the tongue; muscles of the face and scalp and lacrimal, submandibular, and sublingual salivary glands.

CN IV: __________measures eye movement via superior oblique muscles.

CN V: ____________ measures sensory perception from skin of face and scalp and mucous membranes of mouth and nose; muscles of mastication (chewing).

CN VI: _________ measures eye movement via lateral rectus muscles.

_______________ CN III: Measures motor to eye muscles, eye movement via medial and lateral rectus and inferior oblique and superior rectus muscles; lid elevation via the levator muscle; pupil constriction; ciliary muscles.

The nurse is preparing to test the client’s pupillary response. (Place the steps in order)

Have the client open both eyes.
Observe the eye being tested for constriction.
Bring a penlight in from the side of the client’s head.
Have the client close both eyes and dim the lights in the room.
Shine the light in the eye being tested as soon as the client opens his or her eyes.
Note whether the other pupil constricts while the light shines into the eye being tested.

To continue to the cranial nerve VII assessment, the nurse asks the client to first smile, then frown, and then show his or her teeth. While the client performs these tasks, what should the nurse do?

Apply light pressure over the facial nerve.

Observe for symmetric facial movement.

Gently palpate for swelling over the cheeks.

Note how quickly the client completes each task.

The nurse observes for symmetric movement when the client smiles, frowns, or shows his or her teeth. This assessment provides data related to the function of the facial nerve, cranial nerve VII.

The nurse tests cranial nerve XI by asking the client to shrug his or her shoulders. What action should the nurse perform?

Slowly elevate both of the client’s arms.

Apply resistance to the client’s shoulders.

Internally rotate each of the client’s shoulders.

Observe the movement of the client’s clavicles.

The nurse should test the client’s ability to shrug his or her shoulders against resistance with equal strength bilaterally.

The nurse continues the neurological assessment by assessing motor function.

Since the client is lying in bed, which action should the nurse take to observe small muscle movement and coordination?

Use a reflex hammer to elicit arm movement.

Assist the client to sit on the side of the bed.

Stroke the lateral sides of the sole of each foot.

Ask the client to touch the thumb to each finger.

While the client touches her thumb to each finger, the nurse observes for smooth, coordinated movement of the small muscles.

The nurse observes that the client lacks coordination when touching the thumb to the fingers on the left side and decides to further assess upper extremity muscle strength. To assess upper extremity muscle strength, the nurse stands facing the client and holds out both hands toward the client. The nurse asks the client to grip two of the nurse’s fingers with one hand and two fingers with the other hand.

What instruction should the nurse provide next?

Push my fingers back, using both hands at the same time.

Squeeze my fingers with one hand, then with the other.

Pull my fingers forward toward you, one hand at a time.

Squeeze my fingers with both hands at the same time.

When performing a hand grip test, the nurse asks the client to squeeze the nurse’s fingers with both hands simultaneously, the nurse can compare muscle strength bilaterally.

The client’s left upper extremity seems to be weaker than the right upper extremity.

What additional assessment should the nurse perform to validate the finding of unilateral upper extremity weakness?

Perform a palmar drift test.

Complete a Romberg test.

Check for a placing reflex.

Observe for decorticate posturing.

A palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and the eyes closed for 10 to 20 seconds. The weak arm will “drift” downward.

The nurse uses a tuning fork to evaluate what sensory function?

Passive motion.

Two point discrimination.

The client’s ability to sense vibration is assessed by placing a vibrating tuning fork on a bony surface.

the nurse asks the client to close his or her eyes. The nurse places the tuning fork in the palm of the client’s left hand and asks to identify what it is. The client is unable to identify the tuning fork. What action should the nurse take in response to this finding?

Document that the client is exhibiting left-sided astereognosis.

Ask the client to open his or her eyes and identify the object being held.

Place a comb in the client’s left hand and ask him or her to identify the object.

Hold the tuning fork on the back of the client’s hand while trying to identify it.

Stereognosis, the ability to recognize objects by touch, should be assessed by placing a familiar object in the client’s hand. A tuning fork in not a familiar object to many people, so the nurse should replace the fork with a more familiar object, such as a comb.

The nurse continues the neurological assessment by evaluating the client’s deep tendon reflexes (DTRs).

The nurse begins by testing the client’s biceps reflex. With the client’s forearm resting on the nurse’s forearm and the nurse’s thumb over the biceps tendon, what action should the nurse take next to test the client’s biceps reflex?

Ask the client to contract the biceps muscle.

Strike the thumb with the reflex hammer.

Extend and externally rotate the client’s forearm.

Instruct the client to repeatedly clench the fist.

With the client’s forearm slightly flexed and relaxed, the nurse should strike the thumb with the pointed end of the reflex hammer to elicit a response.

The nurse observes contraction of the biceps muscle and flexion of the forearm in response to the attempt to elicit the biceps reflex. What action should the nurse take in response to this finding?

Record the finding as a 4+ deep tendon biceps reflex.

Document that clonus was elicited by the reflex testing.

Explain to the client that the reflex response was normal.

Repeat the test at the same location to confirm the finding.

Explain to the client that the reflex response was normal. The client’s response is normal and should be documented as a 2+ response.

Shortly after completing the admission assessment, the nurse returns to the client’s room and notes a change in condition. The client has slurred speech. Further assessment reveals that the client is no longer able to move either the left arm or leg, and within a few minutes no longer responds to the nurse’s questions. The nurse quickly assesses the client’s level of consciousness by checking for a response to varying stimuli.

What stimuli should the nurse use first to attempt to elicit a response from the client?

Call the client’s name.

Lightly touch the client’s arm.

Pinch the client’s trapezius muscle.

Vigorously shake the client’s shoulder.

The nurse should begin with the least amount of stimulus and progress to the greatest amount of stimulus, observing the amount of stimulus needed to evoke a response by the client.

To objectively assess the client’s level of consciousness, the nurse uses the Glasgow Coma Scale (GCS).

What data should the nurse obtain to complete the client’s GCS rating? Select all that apply

Orientation.

Verbal response.

Babinski reflex.

Motor response.

Pupillary response.

Eye opening response.

The client’s family has arrived and the nurse explains that their parent’s condition has worsened. Several begin to cry and tell the nurse that their parent had often told them about wanting to live a full, long life and did not want any extraordinary measures in the event of a serious illness. The nurse assesses the client’s end-of-life wishes.

In assessing the client’s end-of-life wishes, the nurse remembers that the client’s spouse is deceased. It is most important for the nurse to communicate with which person?

The client’s oldest child.

The client’s designated power of attorney for health care.

The client’s spiritual leader, such as a priest, rabbi, or pastor.

The client’s physician, with whom end of life wishes have been discussed.

he client’s designated power of attorney for health care.

The person designated as a client’s power of attorney for health care has been designated by the client to make health care decisions for the client if the client is unable to do so.

The nurse learns that the client designated the oldest as power of attorney, who tells the nurse that their parent was very clear in end of life wishes and does not wish to have external feeding, ventilation, or resuscitation implemented under any circumstances. To confirm the verbal information regarding the client’s end of life wishes, the client plans to review the client’s living will.

What additional information related to end of life wishes is most important for the nurse to assess?

Organ donor status.

Desired funeral home.

Wishes of other children.

If the client prepared a will.

It is essential for the nurse to assess the client’s wishes regarding organ donation so that any necessary arrangements to preserve organs can be made prior to the client’s death.

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Ch 60 case study

Medical surgery 2 (nur 2214), florida state college at jacksonville, recommended for you.

WR Wendy 2 years ago Thank you, this was most helpful!

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Case Study, Chapter 60, Assessment of Integumentary Function

Laura Jenkins, RN, has recently accepted a position in an extended-care facility. One of her primary responsibilities is to complete physical examinations on patients upon admission and then to perform detailed skin assessments every other day. Because the primary patient population in this facility includes patients over the age of 70, Laura understands that she must be able to differentiate skin changes associated with aging from those that might be related to trauma or pressure. (Learning Objectives 2 and 3)

a. In completing the admission history on newly admitted patients, what types of questions should Laura ask related to medications, nutrition, and past history that affect current skin assessment?  Do you have a hx of hay fever, asthma, hives, eczema, or allergies?  Does anyone in your family have skin problems or rashes?  What medications are you taking?  What skin products or cosmetics do you use?  Do you have a skin reaction after certain foods were eaten? Which foods?

b. Describe normal age-associated skin changes.  Decreased dermal thickness  Degeneration of collagen  Decreased sebum production  Increased vascular fragility  Cherry angiomas (bright red “moles”)  Diminished hair, especially on scalp and pubic area  Dyschromias (color variations)  Solar lentigo (liver spots)  Melasma (dark discoloration of the skin)  Lentigines (freckles)

c. How do age-related changes of the skin affect wound healing in the older adult?

 Cellular changes associated with aging include a thinning at the junction of dermis and epidermis. The result of this thinning is fewer anchoring sites between the two skin layers, which mean that even minor injury or stress to the epidermis can cause it to shear away from the dermis. This phenomenon may account for the increased vulnerability of aged skin to trauma.

d. Laura notes that Mrs. Carson has very dry skin and the vessels in her hands are very prominent. What is Laura’s assessment of these findings?

 Cellular replacement slows as a result of aging. As the dermal layers thin, the skin becomes fragile and transparent

Joe Davis, a 62-year-old patient, is admitted to the hospital with chest injuries after a motor vehicle crash. The client has a history of type 1 diabetes. While assessing the patient, the nurse notes that the patient has several clusters of dull red bumps, smaller than a pencil eraser, spreading to an area the size of a quarter on each lower anterior leg. The skin in the lower extremities is thick; leathery; and has waxy, yellow coloration. (Learning Objective 5)

a. What skin eruptions associated with the patient’s systemic disease does the patient most likely have?

 Diabetic Dermopathy – a frequent occurrence in people with diabetes. These lesions are found on the lower anterior legs, forearms, and thighs and over other bony prominences

b. What is the underlying cause for the skin eruptions?

 They are thought to be caused by diabetes-associated changes in the small vessels that supply the skin and trauma

c. What potential complications are associated with the skin eruptions?

 Stasis Dermatitis  Skin Infections  Leg and Foot Ulcers

Multiple Choice

Course : Medical Surgery 2 (NUR 2214)

University : florida state college at jacksonville.

hesi rn case study integumentary assessment

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