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A: asymmetry: could be indication that it is cancerous
B: Borders are irregular
C: Color: red, blue, black, brown, pink, red
D: diameter: no bigger than the size of a pencil eraser
,what are causes of edema?
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Direct trauma and impairment of venous return
what happens to the hair over the extremities as age increases?
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reduced due to aging or arterial insufficiency
what do you use to assess the moisture of the skin?
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ungloved finger and hand to palpate the skin
when do you change the dressing?
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Remove or change dressings over closed wounds when they become wet
or if the patient has signs or symptoms of infection, and as ordered
,what is the scale nurses use to asses the risk assessment for pressure ulcers?
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braden scale
when measuring weight what do you as the nurse need to remember to ask the
patient to remove before stepping on the scale?
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Remove shoes and heavy outer clothing before standing on scale
what is the normal respiratory rate for infants?
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30-50
when you palpate the texture of the skin what are you feeling for?
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, Smooth or rough
Thin or thick
Tight or supple (flexible)
Indurated (hardened) or soft
what does ventilatory rhythm mean?
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regular/irregular
when would you establish a baseline vital set for a patient?
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upon admission to hospital, first doctor visit
what does gait mean and include?
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Ambulatory, coordinated/uncoordinated movements
Walks smoothly, arms swinging freely at sides
how does health beliefs and motivations effect hygiene?