NUR 216 Module 4 EXAM Latest Update
Questions with Correct Answers Graded
Perfect Score A+
Bulla - Answer -Elevated serous filled greater than 1cm. ex. blister
Capillary Refill - Answer --Depress the nail edge to blanch and then release
-Should be less than two seconds
-Delayed cap refill could indicate cardiovascular or respiratory dysfunction
Crust - Answer -Slightly elevated, dried blood, exudate, pus. ex. scab
Deep Tissue Injury (DTI) - Answer -Discoloration but skin intact, damage to underlying tissue.
Dermis - Answer -The middle layer is composed of connective tissue that is formed by a dense
combination of interconnecting collagen and elastic fibers. It contains blood vessels, hair follicles,
cutaneous nerve endings, sensory receptors, lymphatics, ans sebaceous and sweat glands.
Ecchymosis - Answer -Collection of blood in the dermis greater than 3mm in diameter. Initially
reddish-purple, but will change to blue or yellow during healing, caused by trauma
Edema (accumulation of fluid in tissue) - Answer --Skin appears shinny and tight
-Assess in all areas (arms, legs, abdomen)
-Assess over a bony area (shin)
Edema Scale - Answer -+1 = trace, 2mm, rapid return
+2 = mild, 4mm, 10-15 second return
+3 = moderate, 6mm, prolonged return, 30 seconds
+4 = severe, 8mm, prolonged return, greater than 30 seconds
Elasticity in the older adult. - Answer --Loses elasticity; skin folds and sags.
-Decreased skin turgor.
, Epidermis - Answer -The surface layer is a combination of dead cells on the outside and live cells
on the inside. It takes about a month for cells to move from the inner surface to the outer surface. This is
a way the skin constantly renews itself.
Erosion - Answer -Loss of epidermis, moist. ex. ruptured vesicle
Fissure - Answer -Linear break in skin surface. ex. too dry or moist skin
Hair matrix in the older adult. - Answer -Functioning melanocytes decrease, leading to gray fine
hair.
Hemangiomas - Answer -Vascular Lesion
-Port-wine stain
-Strawberry mark
-Cavernous hemangioma
How often should a diabetic patient inspect feet, toenails, and between toes? - Answer -Daily
Hyperpigmentation - Answer -Occurs when melanin is increased in one area (ex. birthmarks, sun
damage, pregnancy changes)
Hypopigmentation - Answer -Occurs when melanin is somewhat decreased, but not completely
absent in one area (ex. scars, stretch marks, vitiligo)
Inspection and documentation of any skin lesion should include ____. - Answer --Color of lesions
-Height of lesions: flat or raised
-Shape of lesions
-Size of lesions: measured in centimetres
-Location of lesions: single area or generalized
-Presence of lesions: note color and odor
Lesions caused by trauma or abuse - Answer -Vascular Lesion
-Pattern injury
-Hematoma
-Contusion
List expected findings in skin color. - Answer --Combination of melanin (brown) pigments
-Carotene (yellow) pigments
-Underlying vascular bed of blood vessels (red)
List expected findings in skin integrity. - Answer -In general, the skin should be smooth and intact.
Questions with Correct Answers Graded
Perfect Score A+
Bulla - Answer -Elevated serous filled greater than 1cm. ex. blister
Capillary Refill - Answer --Depress the nail edge to blanch and then release
-Should be less than two seconds
-Delayed cap refill could indicate cardiovascular or respiratory dysfunction
Crust - Answer -Slightly elevated, dried blood, exudate, pus. ex. scab
Deep Tissue Injury (DTI) - Answer -Discoloration but skin intact, damage to underlying tissue.
Dermis - Answer -The middle layer is composed of connective tissue that is formed by a dense
combination of interconnecting collagen and elastic fibers. It contains blood vessels, hair follicles,
cutaneous nerve endings, sensory receptors, lymphatics, ans sebaceous and sweat glands.
Ecchymosis - Answer -Collection of blood in the dermis greater than 3mm in diameter. Initially
reddish-purple, but will change to blue or yellow during healing, caused by trauma
Edema (accumulation of fluid in tissue) - Answer --Skin appears shinny and tight
-Assess in all areas (arms, legs, abdomen)
-Assess over a bony area (shin)
Edema Scale - Answer -+1 = trace, 2mm, rapid return
+2 = mild, 4mm, 10-15 second return
+3 = moderate, 6mm, prolonged return, 30 seconds
+4 = severe, 8mm, prolonged return, greater than 30 seconds
Elasticity in the older adult. - Answer --Loses elasticity; skin folds and sags.
-Decreased skin turgor.
, Epidermis - Answer -The surface layer is a combination of dead cells on the outside and live cells
on the inside. It takes about a month for cells to move from the inner surface to the outer surface. This is
a way the skin constantly renews itself.
Erosion - Answer -Loss of epidermis, moist. ex. ruptured vesicle
Fissure - Answer -Linear break in skin surface. ex. too dry or moist skin
Hair matrix in the older adult. - Answer -Functioning melanocytes decrease, leading to gray fine
hair.
Hemangiomas - Answer -Vascular Lesion
-Port-wine stain
-Strawberry mark
-Cavernous hemangioma
How often should a diabetic patient inspect feet, toenails, and between toes? - Answer -Daily
Hyperpigmentation - Answer -Occurs when melanin is increased in one area (ex. birthmarks, sun
damage, pregnancy changes)
Hypopigmentation - Answer -Occurs when melanin is somewhat decreased, but not completely
absent in one area (ex. scars, stretch marks, vitiligo)
Inspection and documentation of any skin lesion should include ____. - Answer --Color of lesions
-Height of lesions: flat or raised
-Shape of lesions
-Size of lesions: measured in centimetres
-Location of lesions: single area or generalized
-Presence of lesions: note color and odor
Lesions caused by trauma or abuse - Answer -Vascular Lesion
-Pattern injury
-Hematoma
-Contusion
List expected findings in skin color. - Answer --Combination of melanin (brown) pigments
-Carotene (yellow) pigments
-Underlying vascular bed of blood vessels (red)
List expected findings in skin integrity. - Answer -In general, the skin should be smooth and intact.
