QUESTIONS & UPDATED ANSWERS
ALL PASSED
PHYSICAL EXAM: INTEGUMENT
Inspect & Palpate: - CORRECT ANSWER Hair: color and condition
(smooth, brittle, fine/coarse, evenly diminished without infestations or alopecia).
Scalp: Mobile without masses, lesions or tenderness
Nails: condition and capillary refill
(rounded, smooth, nailbeds pink without clubbing, capillary refill less than 2 sec.)
Skin: face, trunk, bilateral upper and lower extremities
Color, temperature, condition
(even toned, dry, warm, intact, supple; any presence of lesions- type, size, and
distribution, no erythema, jaundice, ecchymosis, or change in pigmentation
Integumentary System Structures - CORRECT ANSWER Skin
Hair
Nails
*Is the largest organ of the body and the easiest of all systems to assess*
Normal findings: Nails - CORRECT ANSWER Nail surface slightly curved or flat,
smooth, not brittle
Nail base is firm to palpation
Capillary refill- color return is instant
White lines- leukonychia striata
Assess profile sign
- look from the side at angles between nail base and the actual nail
Normal- 160 degrees or less angle
Abnormal Findings: nails (clubbing) - CORRECT ANSWER inner edge of nail elevates,
nail bed angle ↑180˚
,-looks rounder, wider, shiny spongy nail base on palpation
-oxygenation/circulation changes
Abnormal Findings: Nails (onychomyosis) - CORRECT ANSWER fungal infection
Abnormal Findings: Nails (color) - CORRECT ANSWER cyanotic, pale, brown linear
lines, splinter hemorrhages, Beau's lines
Cyanosis - CORRECT ANSWER bluish
possible etiology:
↑ unoxygenated blood
Heart disease
Cold exposure
Light skin: bluish tinge
Dark skin: ashen grey
Pallor - CORRECT ANSWER paleness
possible etiology:
anemia
shock
Light skin: loss of rosy glow
dark skin:
- Ashen gray (dark skin)
- Yellowish brown (brown skin)
Erythema - CORRECT ANSWER redness
Possible etiology:
↑ blood - inflammation, fever, blushing, alcohol
Polycythemia- ↑RBC
Venous stasis
light skin: visble redness
dark skin: diffused; rely on palpation of warmth or edema
jaundice - CORRECT ANSWER yellow
possible etiology:
, ↑ bilirubin- liver dysfunction, chronic disease (cirrhosis), severe burns
infant with immature livers
Renal failure
light skin: Yellow sclera, skin, fingernails, soles, palms, oral mucosa
dark skin: Reliable on sclera, hard palate, palms and soles.
Ecchymosis - CORRECT ANSWER large diffused bluish black
light skin: purplish to yellowish-green
dark skin: Difficult to see, check mouth or conjunctiva
Usually invisible; check oral
Petechiae - CORRECT ANSWER small size pinpoint ecchymosis
light skin: purplish pin points
dark skin: Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.
Brown-Tan - CORRECT ANSWER cortisol deficiency, increased melanin production
light skin: Bronze; Tan to light brown
dark skin: easily masked
Black Skin care considerations - CORRECT ANSWER - stratum corneum in black
people contain more layers of corneal cells
- the pores, sweat glands and sebaceous glands in black skin are larger; dark people
produce more sebum around hair follicles,
assessment basics: minimal skin assessment - CORRECT ANSWER -color
-temperature
- texture
-turgor
-moisture
-integrity
assessment basics: minimal wound assessment - CORRECT ANSWER -thorough pt.
exam
-etiology/wound type
-wound characteristics
•location
•dimensions