Core Exam 4 questions with complete solutions

What integumentary assessment can you not rely on when assessing for dehydration in older adults? skin turgor what is pallor loss of color/pale/gray Pallor is a common indicator of what lack of bloodflow, anemia and shock what is eythema redness erythema most commonly indicates inflammation vasodilation rash elevation of body temp vasofilation is most commonly assosciated with what skin discoloration? erythema a "diminished" pulse strength would be scored 1+ A 2+ pulse strength is described as "brisk, expected" An "increased" pulse strength would be scored 3+ A 4+ pulse strength would best described as "bounding" What describes a 1+ edema "trace" 2mm, rapid response Which edema has a 10 second response time, is about 4 mm, and is considered "mild" 2+ which edema is described as "moderate," is about 6 mm, and has a long respnse time? 3+ edema How would ou describe a 4+ edema "severe" 8mm with a long respnse time what is a late sign of hypoxia cyanosis Inadequate nutrition fecal and urinary incontinence decreased mental status are all risk factors for pressure ulcers diminished sensation excessive body heat advanced age are all risk factors for pressure ulcers what does the Braden scale measure? risk for pressure ulcers You are assessing a patient and find a nonblanchable erythema spot on them, what is this? stage 1 pressure ulcer You are assessing a patients coccyx, and find a spot with patial thickness skin loss involving the epidermis and possibly the dermis. What is this? stage 2 pressure ulcer You are performing a h2t assessment and notice that a patient has full-thickness skin loss involving damage or necrosis to the subcutaneous, what is this stage 3 pressure ulcer A patient is being transferred from an assisted living facility for negligence and abuse, you turn them over and see that their back has full-thickness skin loss with tissue necrosis or damage tot he muscle, bone, or supporting structures. What is this? stage 4 pressure ulcer