The nurse observes that a client has a deep, irregularly shaped ...

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The nurse observes that a client has a deep, irregularly shaped area of skin loss extending into the dermis on the lower extremity. How should the nurse document this finding?
 
  1. Fissure.
  2. Ulcer.
  3. Wheal.
  4. Macule.

Question 2

When performing an assessment of the integumentary system on a client, the nurse should:
 
  1. palpate for edema over the knee.
  2. inspect the inside of the mouth for skin tags.
  3. check color, quantity, and distribution of hair.
  4. check for skin turgor on the forearm.

[Dnite]

Answer to Question 1

Answer: 2

1. Fissures are linear cracks with sharp edges.
2. The description defines the characteristics of an ulcer.
3. A wheal is elevated and fluid-filled, with an irregular border.
4. A macule is a flat, non-palpable change in skin color.

Answer to Question 2

Answer: 3

1. Edema is palpated best over the ankle.
2. Skin tags are found on the external surface of skin.
3. Overall assessment of the hair is part of the integumentary system.
4. Turgor should be checked on the forehead or collarbone.

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[ttt030911]

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