Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUR 230 Exam 2 > chap 14 > Flashcards

chap 14 Flashcards

1
Q

skin is important because

A

provides a physical barrier that protects underlying tissues & organs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

3 layers of skin

A
  • epidermis
  • dermis
  • subcutaneous tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

types of hair

A
  • vellus

- terminal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

purpose of hair

A

filters dust and airborne debris

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

lunula (nail)

A

white portion of nail

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

functions of nails

A
  • protect distal end of fingers/toes
  • enhance precise movement
  • allow extended precision grip
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

subjective data of health assessment

A
  • history of present health concerns
  • personal health history
  • family history
  • lifestyle/health practices
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

personal health history

A
  • sunburns
  • current/previous skin prob
  • hospitalizations
  • surgery
  • allergic reaction
  • recent viral/bacterial infection
  • pregnancy
  • self-injury
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

family history

A
  • recent illness, rash, other skin problems
  • skin cancer
  • keloids
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

inspection (skin assessment)

A
  • color or color variations
  • integrity
  • lesions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

palpation (skin assessment)

A
  • texture
  • thickness
  • moisture
  • temp
  • mobility & turgor
  • edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Braden scale

A
  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction & shear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

perfect braden scale score

A

23

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

mild risk braden scale score

A

15-18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

moderate risk braden scale score

A

13-14

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

high risk braden scale score

A

10-12

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

severe risk braden scale score

A

less than/equal to 9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what does the braden scale measure

A

pressure sore risk

19
Q

hair (objective data)

A
  • color
  • condition
  • texture
  • distribution
  • loss
  • unusual growth patterns
20
Q

nails (objective data)

A
  • grooming
  • color
  • markings
  • shape
  • palpate for texture
  • capillary refill
21
Q

common nursing diagnoses

A
  • readiness for enhanced health management
  • risk for infection
  • risk for imbalanced nutrition
  • impaired skin integrity
  • ineffective health maintenance
  • disturbed body image
22
Q

aging consideration

A
  • decreased perspiration
  • sebum decreases
  • pale
  • skin lesions
  • loss of turgor
  • sagging/wrinkles
  • coarse hair
  • nails become thicker, yellow, brittle
23
Q

pressure ulcers

A

sores on skin @ pressure points

24
Q

contributing factor to pressure ulcers

A

unrelieved pressure

25
Q

high risk for pressure ulcers

A

critical care, long-term care facilities, patients on bedrest

26
Q

stage 1 pressure ulcer

A

intact skin w/ non-blanchable redness

  • painfull
  • firm or soft
  • warm or cooler than adjacent tissue
27
Q

stage 2 pressure ulcer

A

shallow open ulcer w/ pink wound bed

  • intact/open blister
  • shiny/dry shallow ulcer
  • no slough or bruising
28
Q

stage 3 pressure ulcer

A

full thickness tissue loss

  • slough may be present
  • may have tunneling
  • bone/tendon NOT visible
29
Q

stage 4 pressure ulcer

A

full thickness loss w/ bone/tendon/muscle exposed

  • slough present
  • tunneliing
30
Q

What is the greatest risk for MRSA

A

impaired skin integrity

31
Q

most common cancer

A

skin cancer

32
Q

types of skin cancer

A
  • melanoma
  • basal cell carcinoma
  • squamous cell carcinoma
33
Q

ABCDE assessment

A 
a- asymmetry
b-borders
c-color variations
d-diameter
e-evolution
34
Q

risk factors for skin cancer

A
  • sun exposure/tanning
  • family history
  • moles
  • fair skin (burns/freckles easily)
  • age
35
Q

macule

A

darkened area that is flat

36
Q

papule

A

raised area, knotty looking, sometimes pain

37
Q

vesicle

A

fluid filled, blister

38
Q

wheal

A

raised, red areas, allergic-type reaction

39
Q

pustule

A

pus-filled lesions

40
Q

petechia

A
  • type of macule
  • round red/purple
  • associated w/ bleeding tendencies
  • flat
41
Q

ecchymosis

A

bruising

42
Q

ridging in nail

A
  • can be normal

- can be indicative of nutritional problem

43
Q

koilonychia

A
  • seen in iron-deficiency anemia
  • endocrine & cardiac disease
  • “spoon-shaped”

NUR 230 Exam 2 (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions