The nurse is conducting an admission assessment for a client and ...

[schs14]

The nurse is conducting an admission assessment for a client and notes skin vitiligo, which is highly visible even from a distance.
 
  The client asks the nurse to place a No Visitors sign on the door. The client states, I hate the way my skin looks. Some people just stare at me. Which nursing diagnosis should be incorporated into the client's plan of care?
  1. Defensive coping.
  2. Risk for loneliness.
  3. Deficient knowledge.
  4. Disturbed body image.

Question 2

During the assessment of a client's integumentary status the nurse notes vitiligo present bilateral hands. Which analysis of this information is the most appropriate by the nurse?
 
  1. Nodules with ulcerations.
  2. Dark, asymmetrical colored patches.
  3. Grouped vesicles.
  4. Abnormal loss of melanin in patches.

[leahm14]

Answer to Question 1

Correct Answer: 4
A visible skin disorder may trigger psychosocial problems and a disturbed body image. This client has vitiligo, which is a skin condition. The client will exhibit patchy depigmented areas over some or all of the following body areas: face, neck, hands, feet, and body folds. A client with vitiligo may suffer a severe disturbance in body image.

Answer to Question 2

Correct Answer: 4

Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. The term vitiligo does not indicate the presence of nodules with ulcerations; the presence of dark, asymmetrical colored patches; or the presence of grouped vesicles.

[schs14]

Excellent

[chereeb]

TYSM