The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

"Please remove all jewellery so that I can conduct a full assessment."

"I will be touching your skin as part of the process."

"I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

"I will need you to take off your head dress for the entire examination."

Answer and Explanation

Correct Answer : A,B,D

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

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Correct Answer is A

Explanation

A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.

B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.

C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.

D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.

A. The patient's integumentary system is within normal limits for his age B. The patient may have a metabolic condition causing him to feel cold C. The patient has abnormal thinning of skin D. The patient should have elastic turgor

Correct Answer is B

Explanation

A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.

C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.

D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.

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The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?

Correct Answer is A

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The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

Correct Answer is B

Explanation

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