NUR 203 EXAM 1 QUESTIONS AND ANSWERS
What are some subjective data questions to ask for hair, skin, nails? - Answers - 1. Past
history of skin disease (allergies, hives, psoriasis, eczema)
2. Change in Pigmentation
3. Change in mole (size or color)
4. Excessive dryness or moisture
5. pruritus
6. Excessive bruising
7. Rash or lesion
8. Medication (any that cause allergic skin response, increased sunlight sensitivity)
9. Hair loss
10. Change in nails
11. Environmental or occupational hazards (sun exposure, indoor tanning, toxic
chemicals, insect bites)
12. Patient-centered care (daily hygiene; use of soaps, cosmetics or chemicals;p
What are you looking for when inspecting color of the skin? - Answers - general
pigmentation, freckles, moles (nevi), birthmarks
widespread color change
- note color change over entire body skin such as pallor (white), erythema (red),
cyanosis (blue), jaundice (yellow)
- note if color change transient or due to pathology
What is erythema? - Answers - redness of the skin
What is pallor? - Answers - white, pale
What is cyanosis? - Answers - a bluish discoloration of the skin resulting from poor
circulation or inadequate oxygenation of the blood.
What is jaundice? - Answers - A yellowing of the skin and eyes
What are you looking for when assessing the temperature of the skin? - Answers - can
use the palms but the dorsa (backs of hands) more sensitive
skin should be warm, and temperature equal bilaterally; warmth suggests normal
circulatory status
hands and feet may be slightly cooler in a cool environment
- hypothermia
- hyperthermia
What are you looking for when assessing the moisture of the skin? - Answers -
diaphoresis - profuse sweating
,dehydration - dry mucous membranes
What are you looking for when assessing the texture of the skin? - Answers - normal
feels smooth and firm with even surface
What are you looking for when assessing the thickness of the skin? - Answers -
Epidermis is normally thin, callus is an overgrowth
What are you looking for when assessing for edema? - Answers - fluid accumulating in
intercellular spaces
- assess by imprinting thumb firmly against the ankle malleolus on the tibia
- If pressure leaves a dent in the skin this is the "pitting" edema, graded 1+ (mild), 2+
(moderate), 3+ (deep), 4+ (very deeply)
What is mobility? - Answers - skin's ease of rising
What is turgor? - Answers - the ability to return to place promptly when released
How do you assess mobility and turgor? - Answers - pinch up a large fold of skin under
the clavicle
mobility is decreased when edema is present
poor turgor its present with dehydration - the skin recedes slowly or "tents" and stands
by itself
What are you looking for when assessing vascularity and bruising of the skin? -
Answers - - multiple bruises at different stages of healing and excessive bruising of the
knees or elbows should raise concern about physical abuse
- needle marks or tracks from intravenous injection of street drugs may be visible on
antecubital fosse, forearms, or on any available veins
- note tattoos
What are skin lesions you are looking for during a hair, skin, nails assessment? -
Answers - - color
- elevation
- pattern or shape
- size
- location and distribution on body
- any exudate: note color and odor
What is the Melanoma ABC rule? - Answers - A: asymmetry
B: Border irregularity
C: color variation
D: diameter >6 mm
E: elevation and evolving
What are you looking for when inspecting and palpating the hair? - Answers - Color
, - due to melanin production
Texture
- Characteristics range from fine to thick to curly to straight and may be affected by use
of hair care products
Distribution
- tanner staging identifies gender patterns of hair distribution
Lesions
- Identification by looking at scalp and dividing hair into sections
What are you looking for when inspecting and palpating the nails for shape and
contour? - Answers - profile sign; view index finger at its profile and note angle of the
nail base; it should be about 160 degrees
What are you looking for when checking the consistency of the nails? - Answers -
smooth, not brittle or splitting
What are you looking for when assessing the color of the nails? - Answers - normal pink
nail beds
cyanosis is blueish color nail indicating lack of oxygen
pallor is white or very light pink indicating anemia
How do you assess capillary refill? - Answers - - depress nail edge to blanch and then
release, noting return of color, indicates status of peripheral circulation
- color return is normally instant (less than 2 seconds)
- sluggish color return takes longer than 1-2 seconds
What are subjective data questions for head, face, neck exams? - Answers - -
headache?
- head injury?
- dizziness?
- neck pain?
- limitation of motion?
- lumps or swelling?
- self care?
- safety precautions?
- history of injuries?
- masses?
How do you inspect and palpate the skull and what are you looking for? - Answers -
Note general size and shape
- symmetric, comparable to body size
Assess shape: palpate scalp with full hand
- skull normally feels symmetric and smooth
Deformities?
- cranial bones that have normal protrusions are forehead, lateral edge of parietal
bones, occipital bone, and mastoid process behind each ear
What are some subjective data questions to ask for hair, skin, nails? - Answers - 1. Past
history of skin disease (allergies, hives, psoriasis, eczema)
2. Change in Pigmentation
3. Change in mole (size or color)
4. Excessive dryness or moisture
5. pruritus
6. Excessive bruising
7. Rash or lesion
8. Medication (any that cause allergic skin response, increased sunlight sensitivity)
9. Hair loss
10. Change in nails
11. Environmental or occupational hazards (sun exposure, indoor tanning, toxic
chemicals, insect bites)
12. Patient-centered care (daily hygiene; use of soaps, cosmetics or chemicals;p
What are you looking for when inspecting color of the skin? - Answers - general
pigmentation, freckles, moles (nevi), birthmarks
widespread color change
- note color change over entire body skin such as pallor (white), erythema (red),
cyanosis (blue), jaundice (yellow)
- note if color change transient or due to pathology
What is erythema? - Answers - redness of the skin
What is pallor? - Answers - white, pale
What is cyanosis? - Answers - a bluish discoloration of the skin resulting from poor
circulation or inadequate oxygenation of the blood.
What is jaundice? - Answers - A yellowing of the skin and eyes
What are you looking for when assessing the temperature of the skin? - Answers - can
use the palms but the dorsa (backs of hands) more sensitive
skin should be warm, and temperature equal bilaterally; warmth suggests normal
circulatory status
hands and feet may be slightly cooler in a cool environment
- hypothermia
- hyperthermia
What are you looking for when assessing the moisture of the skin? - Answers -
diaphoresis - profuse sweating
,dehydration - dry mucous membranes
What are you looking for when assessing the texture of the skin? - Answers - normal
feels smooth and firm with even surface
What are you looking for when assessing the thickness of the skin? - Answers -
Epidermis is normally thin, callus is an overgrowth
What are you looking for when assessing for edema? - Answers - fluid accumulating in
intercellular spaces
- assess by imprinting thumb firmly against the ankle malleolus on the tibia
- If pressure leaves a dent in the skin this is the "pitting" edema, graded 1+ (mild), 2+
(moderate), 3+ (deep), 4+ (very deeply)
What is mobility? - Answers - skin's ease of rising
What is turgor? - Answers - the ability to return to place promptly when released
How do you assess mobility and turgor? - Answers - pinch up a large fold of skin under
the clavicle
mobility is decreased when edema is present
poor turgor its present with dehydration - the skin recedes slowly or "tents" and stands
by itself
What are you looking for when assessing vascularity and bruising of the skin? -
Answers - - multiple bruises at different stages of healing and excessive bruising of the
knees or elbows should raise concern about physical abuse
- needle marks or tracks from intravenous injection of street drugs may be visible on
antecubital fosse, forearms, or on any available veins
- note tattoos
What are skin lesions you are looking for during a hair, skin, nails assessment? -
Answers - - color
- elevation
- pattern or shape
- size
- location and distribution on body
- any exudate: note color and odor
What is the Melanoma ABC rule? - Answers - A: asymmetry
B: Border irregularity
C: color variation
D: diameter >6 mm
E: elevation and evolving
What are you looking for when inspecting and palpating the hair? - Answers - Color
, - due to melanin production
Texture
- Characteristics range from fine to thick to curly to straight and may be affected by use
of hair care products
Distribution
- tanner staging identifies gender patterns of hair distribution
Lesions
- Identification by looking at scalp and dividing hair into sections
What are you looking for when inspecting and palpating the nails for shape and
contour? - Answers - profile sign; view index finger at its profile and note angle of the
nail base; it should be about 160 degrees
What are you looking for when checking the consistency of the nails? - Answers -
smooth, not brittle or splitting
What are you looking for when assessing the color of the nails? - Answers - normal pink
nail beds
cyanosis is blueish color nail indicating lack of oxygen
pallor is white or very light pink indicating anemia
How do you assess capillary refill? - Answers - - depress nail edge to blanch and then
release, noting return of color, indicates status of peripheral circulation
- color return is normally instant (less than 2 seconds)
- sluggish color return takes longer than 1-2 seconds
What are subjective data questions for head, face, neck exams? - Answers - -
headache?
- head injury?
- dizziness?
- neck pain?
- limitation of motion?
- lumps or swelling?
- self care?
- safety precautions?
- history of injuries?
- masses?
How do you inspect and palpate the skull and what are you looking for? - Answers -
Note general size and shape
- symmetric, comparable to body size
Assess shape: palpate scalp with full hand
- skull normally feels symmetric and smooth
Deformities?
- cranial bones that have normal protrusions are forehead, lateral edge of parietal
bones, occipital bone, and mastoid process behind each ear
