NUR 216 HEALTH ASSESSMENT 2024 TEST 2 (100% Correct Answers)

Health History Questions to ask for Skin, Hair, Nails and Peripheral Vascular System correct answers Have you noticed any change in your skin color... widespread or one area? Do you have a rash, where, does it itch, how long have you had it, and what have you used to treat it? Skin dry or oily, anything to treat it, does it change w/ seasons? Developed any new moles/lesions, have they changed in any way? (color, border, size) How often are you in the sun, do you use sunscreen/protective clothing/hat? Do you have any swelling, if in legs is it both, does it cause pain, what do you do to relieve the swelling and does it occur at any particular time of day? Skin correct answers Assess color of skin for uniformity, typically varies from ivory to a ruddy/deep brown and color changes are more difficult to detect in dark skinned clients. Expect skin color of extremities to be symmetric/similar to the rest of the body (brown pigmentation changes with venous insufficiency, shiny/translucent skin w/out hair on toes/foot indicates arterial insufficiency. Assess for symmetry of temperature and expect warmth.. NOTE circulation reflecting impairment/environmental temp, slightly cooler temps of hands/feet are acceptable Expect smooth, soft, even skin and thicker skin on palms and sole of feet. Assess skin turgor (forearm or sternum), tenting is a delay of skin returning to place indicating dehydration/aging which increases risk for skin breakdown Moisture in axillae is expected otherwise skin should be dry, note diaphoresis, oiliness or excessive dryness w/ scaling/flaking Asses for edema and scale it Assess lesions (ABCDE) for size, color, shape, consistency, elevation, location, distribution, configuration, tenderness, fluid and drainage, measure height, width and depth and observe for any odor, exudate and the amount of exudate/consistency Pallor correct answers -loss of color: best noted in face, conjunctivae, nail beds, palms -indication of anemia, shock or lack of blood flow Cyanosis correct answers Bluish color in the nail beds, lips, mouth mucosa, skin and palms and indicates hypoxia or impaired venous return Jaundice correct answers -yellow: orange of skin, sclera, and mucous membranes -indication of liver dysfunction, red blood-cell destruction Erythema correct answers Redness found in the face, skin, trauma and pressure sore areas and indicates inflammation, localized vasodilation, substance use, sun exposure, rash, and elevated body temp Nails correct answers Assess color of nails Note cleanliness