ANSWERS
What are the steps of the nursing process? - CORRECT ANSWERS assessment, diagnosis,
planning, implementation, evaluation.
Emergency, life threatening, and immediate - CORRECT ANSWERS first priority problems
next in urgency, requiring attention so as to avoid further deterioration - CORRECT
ANSWERS second priority problems
important to the patients health but can be addressed after more urgent problems are
addressed - CORRECT ANSWERS third priority problems
approach to treatment involves multiple disciplines. - CORRECT ANSWERS collaborative
problems.
what the person tells you about themselves - CORRECT ANSWERS subjective data
what is observed by someone else - CORRECT ANSWERS objective data
what are the 8 critical behaviors? - CORRECT ANSWERS location, character/quality,
quantity/severity, timing, setting, aggravating or relieving factors, associated factors, patient's
perception.
absence of color in the skin - CORRECT ANSWERS pallor
,bluish mottled discoloration of skin, nailbeds, and mucous membranes - CORRECT
ANSWERS cyanosis
what should you use to assess skin temperature? - CORRECT ANSWERS dorsum or back of
the hand
how soon should the skin snap back when pinched to assess skin turgor? - CORRECT
ANSWERS 3 seconds or less
solely a color change, flat and circumscribed, less than 1 cm. ex: freckles, hypopigmentation,
measles - CORRECT ANSWERS macule
something you can feel, less than 1 cm, caused by superficial thickening of the epidermis. ex:
mole, wart - CORRECT ANSWERS papule
solid, elevated, hard or soft, larger than 1 cm. may extend deeper into dermis. Ex: fibroma,
intradermal nevi - CORRECT ANSWERS nodule
macules larger than 1 cm. ex: mongolian spot, cafe au lait spot, measles rash - CORRECT
ANSWERS patch
papules coalesce to form surface elevation wider than 1 cm. a plateulike, disk shaped lesion. ex:
psoriasis - CORRECT ANSWERS plaque
superficial, raised, transient, and erythematous, slightly irregular shape from edema. ex:
mosquito bite, allergic reaction - CORRECT ANSWERS wheal
, larger than a few cm in diameter, firm or soft, deeper into dermis. may be benign or malignant.
Ex: lipoma, hemangioma - CORRECT ANSWERS tumor
wheals coalesce to form extensive reaction, intensely pruritic - CORRECT
ANSWERS urticaria (hives)
elevated cavity containing free fluid, up to 1 cm. a blister. ex: herpes simplex, early varicella,
contact dermititis - CORRECT ANSWERS vesicle
larger than 1 cm diameter, usually single chambered, superficial in epidermis, thin walled and
ruptures easily. Ex: friction blister, burns - CORRECT ANSWERS bulla
encapsulated fluid filled cavity in dermis or subcutaneous layer, tensely elevating skin. Ex:
sebaceous cyst - CORRECT ANSWERS cyst
turbid fluid (pus) in the cavity. ex: impetigo, acne - CORRECT ANSWERS pustule
after identifying a lesion, how should it be described? - CORRECT ANSWERS color,
location, size, tenderness, discharge, crustation, type of surface
where is skin turgor best assessed? - CORRECT ANSWERS the sternum, forehead, beneath
the clavicle for the older adult
what is erythema? - CORRECT ANSWERS areas of infection. may appear reddened
where is color best assessed? - CORRECT ANSWERS areas of least pigmentation such as
sclera, conjunctiva, nail beds, lips, tongues, palms, soles