Exam 2: Flashcards
middle layer of skin, made of dense, irregular connective tissue and little fat tissue
dermis
a brown, flat or raised nevus
mole
vascular birthmark that appears as a bright red patch or nodule of extra blood vessels in the skin
hemangioma
small, red, elevated area of the skin
papule
gland that produces sebum
sebaceous gland
highly contagious skin infection, starting as vesicles that rupture and form a honey-colored crust
impetigo
raised erythematous skin lesions that are a result of Type 1 hypersensitivity reaction; also called hives
urticaria
rare, serious infection that can aggressively destroy skin, fat, and muscle
necrotizing fasciitis
gland that secretes sweat through skin pores in response to the sympathetic nervous system
eccrine gland
term for blister
vesicle
large, pigmented spot that may appear in a sun-exposed area; also called age spot or liver spot
lentigo
chronic inflammatory skin condition that typically affects the face
rosacea
skin injury that can result from a thermal or nonthermal source
burn
viral infection caused by the varicella zoster virus; also called shingles
herpes zoster
condition resulting from mite infestation, involving burrowing. Fecal matter left by the mites triggers the inflammatory response.
scabies
infection deep in the dermis and subcutaneous tissue; usually results from a break in the skin
cellulitis
innermost layer of the skin
hypodermis
innermost layer of the skin
hypodermis
a common chronic inflammatory condition triggered by an allergen
atopic dermatitis
parasite that causes superficial fungal infections
tinea
gland that opens into hair follicles in the axilla, scalp, face, and external genitalia
apocrine gland
recessive condition that results in little or no melanin production
albinism
pigment that provides color to the skin as well as protection from UV rays
melanin
protein that strengthens skin
keratin
Why is important to monitor moles?
for changes that could indicate the presence of cancer
What may cause decreased sensations of pain, cold heat, pressure, and touch in the skin?
aging
This is an inflammatory response due to direct contact to an allergen or irritant?
contact dermatitis
What is the least common type of skin cancer, that is also the most serious?
melanoma
An individual who suffered injuries from a house fire arrives at the hospital. As the nurse, what strategy will you utilize to assess the percentage of their body that is burned?
Rule of Nines
What are the 4 primary causes of pressure injuries?
friction, shear, unrelieved pressure, and moisture
Which stage of pressure injury is characterized by intact, nonblanchable skin with the presence of erythema?
stage I
What is the chronic, progressive inflammatory condition that usually affects the face? prevalent in fair-skinned, those who bruise easily, and women
rosacea
What is the most significant risk factor for developing skin cancer?
UV exposure, natural or artificial
what is the most common type of skin cancer?
basal cell carcinoma
What are the ABCD of suspicious skin findings?
asymmetry, border irregularity, color variations, diameter larger than 6mm ( pencil eraser)
This is a form of contact dermatitis that is characterized by a delayed immune response (24-48hrs); type 4 hypersensitivity. ex. poison ivy
allergic contact dermatitis
What occurs when pH is less than 7.35?
Acidosis (blood is too acidic)
What occurs when pH is greater than 7.45?
alkalosis ( too basic)
what results from a deficiency of bicarbonate or an excess of hydrogen?
Metabolic acidosis
what is the respiratory compensatory mechanism for acid-base balance?
change rate and depth of breaths
What condition is most likely to occur within the respiratory system in an individual who is hyperventilating due to an acute anxiety attack?
Respiratory alkalosis (too much CO2 is released)
What is likely to occur in terms of acidity to an individual who has severely depressed breathing rates? (fentanyl, other suppressive drugs, etc)
respiratory acidosis (not enough CO2 released)
What occurs to the blood acidity when respiratory rate increases?
the acidity decreases
What occurs to the blood acidity when respiratory rates decrease?
increased acidity
What acid-base regulation mechanism has the longest effect?
renal/metabolic regulation
What acid-base compensatory mechanism is most slowly activated?
metabolic/renal regulation
What condition is the result of a deficiency of bicarbonate or excess of hydrogen?
metabolic acidosis
Which integumentary condition is characterized by previous infection with chickenpox (varicella), unilateral manifestations, and may cause post-herpetic neuralgia?
Herpes zoster/shingles
What is a good way to treat herpes zoster/shingles?
prevent it via varicella and herpes zoster vaccines
Common type of fungal infection involving the feet, especially the toes (aka athletes foot)
Tenia Pedis
What is the name of the distinct assortment of symptoms that appears in individuals with cardiac tamponade? (low b.p., muffled heart sounds, JVD)?
Beck’s Triad
What are the three manifestations that make up Becks Triad, the system of manifestations that appear with cardiac tamponade?
low b.p.
muffled heart sounds
jugular vein distensions
As the nurse, what procedure can you expect to prepare the patient for who is experiencing cardiac tamponade?
pericardiocentesis (needle used to remove fluid that is compressing the heart)
What describes the force that blood exerts on the walls of the blood vessels?
blood pressure
What condition is characterized by a falling cardiac output, where the blood backs up to pulmonary circulation, causing pulmonary congestion, dyspnea, and activity intolerance?
left-sided failure
What are the treatment options for contact dermatitis?
-identify and remove cause
-wet compresses
-anti-inflammatory creams(corticosteroid agents)
-systemic anti-inflammatory agents
hWhat stage of pressure injury is characterized by non-blanchable erythema of localized area of skin, that is usually found over a bony prominence. -skin is intact, but red (dark skin may appear blue or purple)
Stage I
What stage of pressure injury is characterized by partial thickness loss of the epidermis, erosion or blister, but no exposed subcutaneous tissue? -shallow open ulcer with pink-red wound bed
stage II
What stage of pressure injury does this BEST describe: full thickness skin loss with damage to subcutaneous tissue, where subcutaneous fat may be visible? -no visible tendon, muscle, or bone
stage III
What stage of pressure injury is characterized by full thickness loss of skin? -possible muscle, bone, and tendon exposure, and possible tunneling
Stage IV
What type of injury is expected when there is visible area of purple/maroon skin, and skin is nonblanchable, and upon palpation feels jello-like/mooshy?
deep tissue injury
What type of injury is expected when there is visible area of purple/maroon skin, and skin is nonblanchable, and upon palpation feels jello-like/mooshy?
unstageable
What are the major risks for pressure injuries?
friction, shear, unrelieved pressure, moisture, advancing age, impaired circulation/tissue perfusion, immobilization, malnutrition, decreased sensation or incontinence
What type of burn is characterized by redness, edema, pain, and impact to epidermis? (superficial)
first degree burn
What type of burn is characterized by partial thickness damage, affecting the epidermis AND dermis, with presence of pain, erythema, and blistering?
second degree burn
How may a nurse attempt to avoid burn shock with a patient who has severe burns? (burn shock is caused by loss of fluid)
-place patient in Trendelenburg (feet above head), and cover them with a coat/blanket
-administer fluids to prevent dehydration
-reverse isolation room
Rule of 9’s: head and neck
9%
Rule of 9’s: arms (each)
9%
Rule of 9’s: trunk (anterior and posterior individually)
18% each
Rule of 9’s: legs (each)
18% each
Rule of 9’s: genitalia & perineum
1%
What should the nurse educate any patient about with pruritus?
cease scratching to prevent secondary bacterial infection
What are the manifestations of cellulitis?
swollen, warm, tender area of erythema. Leukocytosis, malaise, etc.
Can lead to necrotizing fasciitis and sepsis
What condition is caused by the reawakening of of varicella-zoster virus on a nerve commonly caused by stress?
herpes zoster (shingles)
What are the manifestations of herpes zoster/shingles?
extremely sensitive skin, pain, paresthesia (tingling), red/silvery vesicular rash, itching
-may also result in post-herpetic neuralgia (pain after disease is gone), blindness
What are manifestations related to hypernatremia?
excess thirst, dry/sticky mucous membranes, seizures, lethargy, coma, b.p. changes, tachycardia, weak and thready pulse, edema, decreased urine output
What are manifestations of hyponatremia?
diminished deep tendon reflexes, confusion, coma, seizures, muscle weakness, g.i. upset, headache, pulse changes, dry mucous membranes
What is the major concern with fluctuation of potassium outside of the expected range?
EKG changes
How would hypernatremia likely be treated?
fluid replacement (oral or hypotonic solutions) and diuretics
How would hyponatremia likely be treated?
limit fluids and increase dietary sodium
What may happen to the heart if potassium is too low?
cardiac arrest
What system is likely to be affected by hypercalcemia?
neuromuscular system (confusion, headache, decreased deep tendon reflex
You are observing a clients b.p. and observe a carpal spasm(Trousseau’s Sign) , which electrolyte imbalance might you expect?
hypocalcemia
What is Chvostek’s Sign, and which electrolyte imbalance is it associated with?
twitch of facial muscles when tapping on cheek related to hypocalcemia
What compensatory mechanism is activated in the kidney’s when renal blood flow is decreased, as with hypotensive states?
RAAS (renin-angiotensin-aldosterone system)
What is referred to as generalized edema?
anasarca
What is referred to as swelling in the abdomen due to excess fluid?
ascites
How may the body compensate for hypovolemia?
increased thirst and heart rate, decreased urine output
What system of maintaining acid-base balance is immediate, and is comprised of chemicals that combine with an acid or base to alter pH?
buffer system
What is the most significant buffer system?
bicarbonate-carbonic acid system
What type of compensatory mechanism is trademarked by Kussmaul respirations? Why do they occur?
metabolic acidosis
-deep, rapid respirations in attempt to eliminate excess acid by exhaling CO2
what is referred to as the strength of contraction of the heart?
inotropic effect
What is the term for the amount of blood the heart pumps in one minute?
cardiac output
What type of heart failure is characterized by blood backing up into pulmonary circulation, causing pulmonary congestion, dyspnea, and activity intolerance?
left-sided heart failure
Which heart failure causes blood to back up into the peripheral circulation, causing edema & weight gain?
right-sided heart failure
As the nurse, you assessed the client and find low b.p., muffled heart sounds, and JVD, which cardiovascular condition might you suspect? What is this unique trio of manifestations called?
cardiac tamponade
What is the life-threatening cardiac compression from fluid accumulation called?
cardiac tamponade
What is referred to as the death of the myocardium from a sudden blockage of coronary artery blood flow?
Myocardial infarction
What may you expect with troponin levels in an individual who has had a myocardial infarction within the last 2 weeks?
elevation/increased
What type of shock is characterized by the left ventricle’s inability to maintain adequate cardiac output?
cardiogenic shock
What is the cause of cardiogenic shock?
myocardial damage (heart attack), arrythmias, etc
What are the manifestations of endocarditis?
flu-like symptoms, Osler Nodes (tender, raised subcutaneous lesions on finger nails and toes), Janeway Lesions (small, non-tender lesions on palms or soles of feet), Roth Spots (eye lesions)
What type of valvular disease leads to hypertrophy, and may be accompanied by atresia (failure to open valve)?
stenosis
What type of valvular disease causes dilation due to insufficient closure/ bidirectional blood flow?
regurgitation
What is hypertension?
prolonged elevation in b.p. that creates excessive cardiac workload
What is dyslipidemia/ hyperlipidemia?
high levels of lipids in the blood
What condition is a chronic inflammatory disease triggered by a vessel wall injury and characterized by thickening/hardening lesions calcifying on the arterial wall?
atherosclerosis
What is peripheral vascular disease?
narrowing of/atherosclerosis of the arteries in the legs/ arterial insufficiency
What are the manifestations of PVD?
intermittent claudication (pain w/ walking), shiny, hairless legs, and cool skin
What is PUD (peptic ulcer disease)?
erosive lesions affecting the muscularis mucosa of the stomach or duodenum?
What is cholelithiasis? What type of diet causes this condition?
gallstones
high fat diet
What is GERD (gastroesophageal reflux disease)?
the inappropriate movement of stomach contents into the esophagus, causing irritation to esophageal mucosa
Which inflammatory bowel disease is trade-marked by a cobblestone appearance or skip lesions to the g.i. lining?
Chrohn’s Disease
Which IBD is caused by stress?
IBS (irritable bowel syndrome)
Which IBD is characterized by erosions seen by colonoscopy?
Ulcerative Colitis
What condition is identified by out-pouching of the submucosal layer of the intestines that pushes through the muscular layer?
diverticular disease
What happens to the abdomen during peritonitis? other manifestations?
rigidity
-decreased peristalsis, sepsis, intestinal obstruction
Dark, tarry stool associated with a significant amount of bleeding in the g.i. tract?
melena
Blood in the vomitus (coffee ground appearance)?
hematemesis
What are concerns for diarrhea/vomiting?
dehydration and electrolyte imbalance
What are the manifestations of liver cirrhosis?
ascites, jaundice, portal hypertension, intense itching, clay-colored stools, dark urine, clotting changes
What is the condition by which a section of the stomach protrudes upward through an opening in the diaphragm? What are the risks?
hiatal hernia
advancing age, smoking, obesity
What type of shock may present with a rapid and thready pulse?
hypovolemic shock
What is the priority nursing intervention for a client who has hyperkalemia?
get an EKG
What is referred to as thin, weak walls of the left ventricle? What does this condition cause?
dilated cardiomyopathy
decreased cardiac output
What type of IV fluid expands fluid volume?
isotonic
What is the sign for Crohn’s Disease?
skip lesions
What manifestations are associated with a small bowel obstruction?
colicky pain (sudden and severe)
What type of solution moves fluid into a cell?
hypotonic
What type of solution moves fluid out of a cell?
hypertonic
What type of solution is responsible for putting more fluid in the intravascular space? When would you use this solution?
isotonic
hypovolemia
In terms of Na+, what would cause diminished deep tendon reflexes and g.i. disturbances?
hyponatremia
Which electrolyte disturbances are Trousseau’s and Chvostek’s signs related to?
hypocalcemia
What refers to the group of conditions characterized by enlargement, thickening, or replacement of myocardium with scar tissue?
cardiomyopathy
What annual test may be used in individuals with hyperlipidemia to assess risks?
ASCVD (atherosclerotic cardiovascular disease) risk calculator
what hormone increases blood volume by increasing the reabsorption of Na+ in the kidneys?
aldosterone
What is the normal blood pH?
7.35-7.45
What is normal range of PaCO2?
45-35 mmHg
What is the normal range of HCO3?
22-26 mEQ/L
