EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
Focus of skin assessment - ANSWER - color
-pigmentation
- moisture
-temperature
- texture
- turgor
-hygiene
- lesions
pitting edema - ANSWER pressure forces fluid into the underlying tissue, causing an indentation that
slowly fills
non-pitting edema - ANSWER pressure leaves no indentation because fluid is viscous, the tissue may feel
tight/firm
describing lesions - ANSWER -type
-location
-size
-shape
-elevation
-texture
-exudate
- color
-distribution
-configuration
,EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
healing by primary intention - ANSWER •Closely approximated edges
•Minimal proliferation
•1st day- WBC proliferation (cells dividing)
•2-3 days-macrophages have removed debris
•Collagen lines up and by 5th day fills in
•Epithelialization
-REEDA
-Stitch -> deep tissue (up -> down)
- heals fast because it's closed
Healing by secondary intention - ANSWER •Wound edges far apart and tissue loss
•Requires contraction, extensive cell proliferation,
revascularization
•Re-epithelialized from the margins, collagen deposited in the granulating tissue
•Granulation reabsorbed and replaced by scar
-slower (down -> up)
what causes pressure ulcers? - ANSWER ischemia, a deficiency in the blood supply to the tissue
Risk factors of pressure ulcers - ANSWER friction & shearing, immobility, inadequate nutrition, fecal &
urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced
age, and presence of chronic conditions
braden scale - ANSWER predicting pressure sore risk
- consists of six subscales (sensory, mobility, perception, nutrition, moisture, friction and shear, and
activity)
- score of 18 or less indicates risk
,EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
assessing hair - ANSWER - age
-ethnicity
-hair care practices
-evenness, thickness, texture, hygiene
-note presence of infections and infestations
assessing nails - ANSWER -history
- artificial nails or polish
-inspect fingernail plate & skin around nails
-inspect texture
-shape, color of nail bed
-capillary refill needs to be within 2 seconds of testing
-inspect for clubbing
senile purpura - ANSWER -older adults experience bruising easily
-a minor trauma may produce dark red discolored areas
pruritus - ANSWER irritating sensation that creates an urge to scratch that can involve any part of the
body
alopecia - ANSWER significant hair loss
hirsutism - ANSWER shaggy or excessive hair
vitiligo - ANSWER complete absence of melanin pigment in patchy areas of white or light skin on the
face, neck, hands, feet, body folds, and around orifices
, EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
erythema - ANSWER intense redness of the skin from excess blood in the dilated superficial capillaries
What is NREM? - ANSWER non-rapid eye movement, it occurs when activity in the RAS is inhibited,
about 75% to 80% of sleep is NREM sleep
What are the stages of NREM? - ANSWER 1. Is the stage of very light sleep and lasts only a few minutes.
During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and
respiratory rates drop slightly. The sleeper can be readily awakened and may deny that he or she were
sleep
2. This is the stage of sleep during which body processes continue to slow down, the eyes are generally
still, the heart and respiratory rates drop slightly, and body temperature falls. Individuals might need to
be awaken with a touch or shaking
3. This is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a
30-sec period. During deep sleep, the sleeper's heart and respiratory rates drop 20% to 30% below those
exhibited waking hours, the individual is difficult to arouse. This person is not disturbed by sensory
stimuli, the skeletal muslces are very relaxed, reflexes are diminished, and snoring is most likely to
occur, this stage is essential for restoring energy and releasing important growth hormones
Why is sleep essential? - ANSWER during sleep, the growth hormone is secreted and cortisol is inhibited
What is REM? - ANSWER During REM sleep, it usually recurs about every 90 minutes and lasts 5 to 30
minutes, most dreams take place during REM sleep but usually will not be remembered unless the
person arouses briefly at the end of REM sleep
During REM slep the brain is highly active, and brain metabolism may increase as much as 20%.
During REM sleep, levels of acetylcholine and dopamine increase
It is thought that the regions of the brain that are used in learning, thinking and organizing information
are stimulated during REM sleep
137 complete solutions.
EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
Focus of skin assessment - ANSWER - color
-pigmentation
- moisture
-temperature
- texture
- turgor
-hygiene
- lesions
pitting edema - ANSWER pressure forces fluid into the underlying tissue, causing an indentation that
slowly fills
non-pitting edema - ANSWER pressure leaves no indentation because fluid is viscous, the tissue may feel
tight/firm
describing lesions - ANSWER -type
-location
-size
-shape
-elevation
-texture
-exudate
- color
-distribution
-configuration
,EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
healing by primary intention - ANSWER •Closely approximated edges
•Minimal proliferation
•1st day- WBC proliferation (cells dividing)
•2-3 days-macrophages have removed debris
•Collagen lines up and by 5th day fills in
•Epithelialization
-REEDA
-Stitch -> deep tissue (up -> down)
- heals fast because it's closed
Healing by secondary intention - ANSWER •Wound edges far apart and tissue loss
•Requires contraction, extensive cell proliferation,
revascularization
•Re-epithelialized from the margins, collagen deposited in the granulating tissue
•Granulation reabsorbed and replaced by scar
-slower (down -> up)
what causes pressure ulcers? - ANSWER ischemia, a deficiency in the blood supply to the tissue
Risk factors of pressure ulcers - ANSWER friction & shearing, immobility, inadequate nutrition, fecal &
urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced
age, and presence of chronic conditions
braden scale - ANSWER predicting pressure sore risk
- consists of six subscales (sensory, mobility, perception, nutrition, moisture, friction and shear, and
activity)
- score of 18 or less indicates risk
,EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
assessing hair - ANSWER - age
-ethnicity
-hair care practices
-evenness, thickness, texture, hygiene
-note presence of infections and infestations
assessing nails - ANSWER -history
- artificial nails or polish
-inspect fingernail plate & skin around nails
-inspect texture
-shape, color of nail bed
-capillary refill needs to be within 2 seconds of testing
-inspect for clubbing
senile purpura - ANSWER -older adults experience bruising easily
-a minor trauma may produce dark red discolored areas
pruritus - ANSWER irritating sensation that creates an urge to scratch that can involve any part of the
body
alopecia - ANSWER significant hair loss
hirsutism - ANSWER shaggy or excessive hair
vitiligo - ANSWER complete absence of melanin pigment in patchy areas of white or light skin on the
face, neck, hands, feet, body folds, and around orifices
, EVCC Nursing 110 Exam #3 (correct one)
137 complete solutions.
erythema - ANSWER intense redness of the skin from excess blood in the dilated superficial capillaries
What is NREM? - ANSWER non-rapid eye movement, it occurs when activity in the RAS is inhibited,
about 75% to 80% of sleep is NREM sleep
What are the stages of NREM? - ANSWER 1. Is the stage of very light sleep and lasts only a few minutes.
During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and
respiratory rates drop slightly. The sleeper can be readily awakened and may deny that he or she were
sleep
2. This is the stage of sleep during which body processes continue to slow down, the eyes are generally
still, the heart and respiratory rates drop slightly, and body temperature falls. Individuals might need to
be awaken with a touch or shaking
3. This is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a
30-sec period. During deep sleep, the sleeper's heart and respiratory rates drop 20% to 30% below those
exhibited waking hours, the individual is difficult to arouse. This person is not disturbed by sensory
stimuli, the skeletal muslces are very relaxed, reflexes are diminished, and snoring is most likely to
occur, this stage is essential for restoring energy and releasing important growth hormones
Why is sleep essential? - ANSWER during sleep, the growth hormone is secreted and cortisol is inhibited
What is REM? - ANSWER During REM sleep, it usually recurs about every 90 minutes and lasts 5 to 30
minutes, most dreams take place during REM sleep but usually will not be remembered unless the
person arouses briefly at the end of REM sleep
During REM slep the brain is highly active, and brain metabolism may increase as much as 20%.
During REM sleep, levels of acetylcholine and dopamine increase
It is thought that the regions of the brain that are used in learning, thinking and organizing information
are stimulated during REM sleep
