WITH DETAILED SOLUTIONS 2026
◉ Nursing process: Answer: Assessment, diagnosis, planning,
implementation, evaluation
◉ What is the order of a Health Assessment: Answer: Inspection,
palpation, percussion, auscultation (exception w/ abdomen =
IAPaPe)
◉ Specialized examination occur how often when in the hospital?
Answer: Every 8 hours
◉ Define Admission Assessment: Answer: PMHx, allergies, home
meds, immunizations, physical assessment data, cultural/spiritual
◉ Define Shift Assessment: Answer: Physical assessment and any
changes from admission, q4h depending on severity, do BEFORE
giving meds/treatment
◉ Define initial assessment: Answer: Thorough and accurate,
complete rapidly, but not in a hurry, re-assess q4-8h (shift
assessment)
,◉ Special assessments include: Answer: Skin Risk, hourly rounds,
fall risk, IV/catheter assessments, neuro assessment
◉ Layers of skin: Answer: Epidermis: outer layer; protective barrier
Dermis: underneath; nerve, blood vessels, and hair follicles
Subcutaneous: layer of fat that provides protection
◉ Sebaceous glands: Answer: Produce sebum which is an adipose
like-liquid that comes out of the follicles that provide moisture to
skin
◉ What are the 2 types of sweat glands? Answer: Eccrine glands
(sweat glands that release saline solution)
Apocrine glands (produce adipose-like substance that is released in
the axillae, nipples, anal/private part area, naval)
◉ Name the two types of hair: Answer: Vellus: short, fine,
inconspicuous, unpigemented (over most of our body)
Terminal: coarser, thicker, conspicuous, usually pigmented (on head,
pubic hair)
,◉ Anatomy of the nail: Answer: Note the body of the nail (nail plate),
lunula, and cuticle
◉ Functions of the skin: Answer: Protection, barrier, sensory
perception (touch, pain, pressure, temp.), regulates body temp, ID,
synthesize vitamin D, nonverbal communication, wound repair,
excretion of metabolic waste (salt)
◉ Inspect and palpate the skin for: Answer: Color, moisture, temp.,
texture, thickness, mobility and turgor, edema, vascularity +
bruising, lesions
◉ Cyanosis: Answer: Blue-pigmented color; often seen in new borns;
not normal in an adult
◉ Erythema: Answer: Pink-pigmented color; sometimes seen with a
fever
◉ Carotemia: Answer: Orange-pigmented color; too many vitamins
in their system; won't cause harm to children or adults
◉ Jaundice: Answer: Yellow-pigmented color; yellowing in the
sclera/skin
, ◉ Cafe au Lait spot: Answer: Large freckles; birth mark
◉ Vitiligo: Answer: Loss of pigmentation of the skin; get white spots;
more noticeable in darker skin individuals
◉ Tinea Veriscolor: Answer: Infection from a fungus; with light
skinned individuals, the spots are dark; with darker skinned
individuals, the spots are lighter
◉ Stage I pressure ulcer: Answer: Intact skin appears red, but
unbroken. Skin does NOT blanch
◉ Stage II pressure ulcer: Answer: Partial-thickness skin erosion
with loss of epidermis/dermis. Superficial ulcer looks shallow like
and abrasion or open blister (red-pink wound)
◉ Stage III pressure ulcer: Answer: Full-thickness extending into
sub-q resembling a crater. Might not see muscle, bone, or tendon.
◉ Stage IV pressure ulcer: Answer: Involves all skin layers and
extending into support tissue. Exposes muscle, tendon, or bone, and
may slough (stringy matter in wound bed) OR eschar (black/brown
necrotic tissue)