NUR 216 Exam 2 Study Guide|/ |/ |/ |/ |/
QUESTIONS WITH ANSWERS
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Assessment techniques for integumentary - CORRECT ANSWERS
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✔✔inspection and palpation
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Inspection and palpation in skin color: expected findings -
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CORRECT ANSWERS ✔✔-general pigmentation even and
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consistent
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-appropriate for each ethnicity: whitish pink for light or dark
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brown with yellow or olive tones
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-increased pigmentation if exposed to sun
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-hyperpigmentation: birthmarks, sun damage, freckles, tan lines. |/ |/ |/ |/ |/ |/
-HyPOpigmentation: scars, stretch marks, vitiligo. |/ |/ |/ |/
Inspection and palpation in skin color: unexpected findings -
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CORRECT ANSWERS ✔✔pallor
|/ |/ |/
erythema
cyanosis
juandice
pallor - CORRECT ANSWERS ✔✔loss of color
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black skin tones are gray especially in mucous membranes.
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Brown skin tones a change to yellow-brown.
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pale skin tones a loss of redness undertones
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,best places to see are: conjunctivae, lips, buccal, and mucosa
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Causes: Anemia, shock, lack of blood flow
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Erythema - CORRECT ANSWERS ✔✔redness |/ |/ |/ |/
hard to see on darker clients.
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face, skin and pressure sore areas.
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palpate skin for warmth and inflamed areas hard or tenderness
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causes: inflammation/infection, vasodilation(dilation of blood
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vessels, increases BP)
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Cyanosis - CORRECT ANSWERS ✔✔light skin tones: bluish
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palms and soles for darker skin tones.
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brown skin tones change to a yellow.
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black skin tones look grey.
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best place to note in darker skin tones: mucous membranes and
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nail beds
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Causes: hypoxia or impaired venous return
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Juandice - CORRECT ANSWERS ✔✔yellowing of the skin
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skin, sclera, mucosa membranes
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causes: liver dysfunction/disease, RBC destruction
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temperature inspection for skin - CORRECT ANSWERS ✔✔use |/ |/ |/ |/ |/ |/ |/
dorsal of hand
|/ |/ |/
expected findings: |/
,-skin is warm |/ |/
-temperature is equal bilaterally |/ |/ |/
moisture inspection for skin - CORRECT ANSWERS ✔✔expected:
|/ |/ |/ |/ |/ |/ |/
dry
|/
unexpected: diaphoretic (sweating heavily) |/ |/ |/
texture inspection for skin - CORRECT ANSWERS ✔✔expected:
|/ |/ |/ |/ |/ |/ |/
smooth
|/
expected variations: acne, wrinkles, scars
|/ |/ |/ |/
unexpected: velvety skin (thyroid disease) roughness, dryness|/ |/ |/ |/ |/ |/
(xerosis), flakiness (indicates dehydration)
|/ |/ |/ |/
turgor inspection for skin - CORRECT ANSWERS ✔✔dehydration or
|/ |/ |/ |/ |/ |/ |/ |/
normal aging for a "tent"
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clavicle location is ideal |/ |/ |/
edema in skin - CORRECT ANSWERS ✔✔accumulation of fluid in
|/ |/ |/ |/ |/ |/ |/ |/ |/
the tissue
|/ |/
-skin i shiny and taut
|/ |/ |/ |/
-most common in legs |/ |/ |/
-assess over a bony area |/ |/ |/ |/
-assess in all areas arms, legs and abdomen.
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+1 is trace 2mm rapid return
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+2 is mild 4mm 10-15 second return
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+3 is moderate 6mm prolonged return
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, +4 is severe 8mm prolonged return
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double amount for mm amount |/ |/ |/ |/
vascular lesions - CORRECT ANSWERS ✔✔results from blood
|/ |/ |/ |/ |/ |/ |/
leaking from blood vessels into the dermis
|/ |/ |/ |/ |/ |/ |/
-Petechiae: infection or trauma. |/ |/ |/
-Ecchymosis: trauma (collection of blood in dermis >3 mm in |/ |/ |/ |/ |/ |/ |/ |/ |/
diameter, can change colors during healing (lead).
|/ |/ |/ |/ |/ |/ |/ |/
-purpura: infection or bleeding disorder |/ |/ |/ |/
note the following for lesions - CORRECT ANSWERS ✔✔color
|/ |/ |/ |/ |/ |/ |/ |/
height (above the skin) |/ |/ |/
shape |/
size (measured in cm)
|/ |/ |/
-location and distribution on the body, if any exudate note the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
color and odor. COCA (color, odor, consistency, amount)
|/ |/ |/ |/ |/ |/ |/ |/
ABCDEs of melanoma - CORRECT ANSWERS ✔✔A= asymmetry
|/ |/ |/ |/ |/ |/ |/
B= border (irregular)
|/ |/
C= varies (brown, balck, tan)
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D= diameter (usually >6mm)
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E= evolving (looks different?)
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flat lesions: macule - CORRECT ANSWERS ✔✔freckles, mole,
|/ |/ |/ |/ |/ |/ |/
measles, scarlet fever
|/ |/ |/
QUESTIONS WITH ANSWERS
|/ |/ |/
Assessment techniques for integumentary - CORRECT ANSWERS
|/ |/ |/ |/ |/ |/
✔✔inspection and palpation
|/ |/ |/
Inspection and palpation in skin color: expected findings -
|/ |/ |/ |/ |/ |/ |/ |/
CORRECT ANSWERS ✔✔-general pigmentation even and
|/ |/ |/ |/ |/ |/
consistent
|/
-appropriate for each ethnicity: whitish pink for light or dark
|/ |/ |/ |/ |/ |/ |/ |/ |/
brown with yellow or olive tones
|/ |/ |/ |/ |/ |/
-increased pigmentation if exposed to sun
|/ |/ |/ |/ |/
-hyperpigmentation: birthmarks, sun damage, freckles, tan lines. |/ |/ |/ |/ |/ |/
-HyPOpigmentation: scars, stretch marks, vitiligo. |/ |/ |/ |/
Inspection and palpation in skin color: unexpected findings -
|/ |/ |/ |/ |/ |/ |/ |/
CORRECT ANSWERS ✔✔pallor
|/ |/ |/
erythema
cyanosis
juandice
pallor - CORRECT ANSWERS ✔✔loss of color
|/ |/ |/ |/ |/ |/
black skin tones are gray especially in mucous membranes.
|/ |/ |/ |/ |/ |/ |/ |/
Brown skin tones a change to yellow-brown.
|/ |/ |/ |/ |/ |/
pale skin tones a loss of redness undertones
|/ |/ |/ |/ |/ |/ |/
,best places to see are: conjunctivae, lips, buccal, and mucosa
|/ |/ |/ |/ |/ |/ |/ |/ |/
Causes: Anemia, shock, lack of blood flow
|/ |/ |/ |/ |/ |/
Erythema - CORRECT ANSWERS ✔✔redness |/ |/ |/ |/
hard to see on darker clients.
|/ |/ |/ |/ |/
face, skin and pressure sore areas.
|/ |/ |/ |/ |/
palpate skin for warmth and inflamed areas hard or tenderness
|/ |/ |/ |/ |/ |/ |/ |/ |/
causes: inflammation/infection, vasodilation(dilation of blood
|/ |/ |/ |/
vessels, increases BP)
|/ |/ |/
Cyanosis - CORRECT ANSWERS ✔✔light skin tones: bluish
|/ |/ |/ |/ |/ |/ |/
palms and soles for darker skin tones.
|/ |/ |/ |/ |/ |/
brown skin tones change to a yellow.
|/ |/ |/ |/ |/ |/
black skin tones look grey.
|/ |/ |/ |/
best place to note in darker skin tones: mucous membranes and
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
nail beds
|/ |/
Causes: hypoxia or impaired venous return
|/ |/ |/ |/ |/
Juandice - CORRECT ANSWERS ✔✔yellowing of the skin
|/ |/ |/ |/ |/ |/ |/
skin, sclera, mucosa membranes
|/ |/ |/
causes: liver dysfunction/disease, RBC destruction
|/ |/ |/ |/
temperature inspection for skin - CORRECT ANSWERS ✔✔use |/ |/ |/ |/ |/ |/ |/
dorsal of hand
|/ |/ |/
expected findings: |/
,-skin is warm |/ |/
-temperature is equal bilaterally |/ |/ |/
moisture inspection for skin - CORRECT ANSWERS ✔✔expected:
|/ |/ |/ |/ |/ |/ |/
dry
|/
unexpected: diaphoretic (sweating heavily) |/ |/ |/
texture inspection for skin - CORRECT ANSWERS ✔✔expected:
|/ |/ |/ |/ |/ |/ |/
smooth
|/
expected variations: acne, wrinkles, scars
|/ |/ |/ |/
unexpected: velvety skin (thyroid disease) roughness, dryness|/ |/ |/ |/ |/ |/
(xerosis), flakiness (indicates dehydration)
|/ |/ |/ |/
turgor inspection for skin - CORRECT ANSWERS ✔✔dehydration or
|/ |/ |/ |/ |/ |/ |/ |/
normal aging for a "tent"
|/ |/ |/ |/ |/
clavicle location is ideal |/ |/ |/
edema in skin - CORRECT ANSWERS ✔✔accumulation of fluid in
|/ |/ |/ |/ |/ |/ |/ |/ |/
the tissue
|/ |/
-skin i shiny and taut
|/ |/ |/ |/
-most common in legs |/ |/ |/
-assess over a bony area |/ |/ |/ |/
-assess in all areas arms, legs and abdomen.
|/ |/ |/ |/ |/ |/ |/
+1 is trace 2mm rapid return
|/ |/ |/ |/ |/
+2 is mild 4mm 10-15 second return
|/ |/ |/ |/ |/ |/
+3 is moderate 6mm prolonged return
|/ |/ |/ |/ |/
, +4 is severe 8mm prolonged return
|/ |/ |/ |/ |/
double amount for mm amount |/ |/ |/ |/
vascular lesions - CORRECT ANSWERS ✔✔results from blood
|/ |/ |/ |/ |/ |/ |/
leaking from blood vessels into the dermis
|/ |/ |/ |/ |/ |/ |/
-Petechiae: infection or trauma. |/ |/ |/
-Ecchymosis: trauma (collection of blood in dermis >3 mm in |/ |/ |/ |/ |/ |/ |/ |/ |/
diameter, can change colors during healing (lead).
|/ |/ |/ |/ |/ |/ |/ |/
-purpura: infection or bleeding disorder |/ |/ |/ |/
note the following for lesions - CORRECT ANSWERS ✔✔color
|/ |/ |/ |/ |/ |/ |/ |/
height (above the skin) |/ |/ |/
shape |/
size (measured in cm)
|/ |/ |/
-location and distribution on the body, if any exudate note the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
color and odor. COCA (color, odor, consistency, amount)
|/ |/ |/ |/ |/ |/ |/ |/
ABCDEs of melanoma - CORRECT ANSWERS ✔✔A= asymmetry
|/ |/ |/ |/ |/ |/ |/
B= border (irregular)
|/ |/
C= varies (brown, balck, tan)
|/ |/ |/ |/
D= diameter (usually >6mm)
|/ |/ |/
E= evolving (looks different?)
|/ |/ |/
flat lesions: macule - CORRECT ANSWERS ✔✔freckles, mole,
|/ |/ |/ |/ |/ |/ |/
measles, scarlet fever
|/ |/ |/
