Exam 2- Skin

Question 1

Stage 4 pressure ulcer

Answer 1

Full-thickness

Involves all skin layers

Extends into supporting back tissue

Exposes muscle, tendon, bone

May show slough -stringy matter attached to Eschar (black or brown necrotic tissue)

Question 2

Arterial ulcer characteristics

Answer 2

Well-defined edges

No bleeding

Question 3

Wheal skin lesion

Answer 3

Superficial

Raised

Transient

Erythematous

Slight irregular shape from edema

Question 4

Venous ulcer

Answer 4

Bleeding and irregular edges

Question 5

Vesicle skin lesion

Answer 5

Elevated cavity containing free fluid

Up to 1cm

Question 6

Pustule

Answer 6

Pus in cavity

Circumscribed

Elevated

Question 7

Annular lesion

Answer 7

Begins in center

Spread to periphery

Circular

Question 8

Gyrate

Answer 8

Spiral shape

Twisted

Snake like

Question 9

Polycyclic

Answer 9

Annular

Grow together

Question 10

Confluent lesion

Answer 10

Annular

Run together

Question 11

Edema

Answer 11

Fluid accumulating in interstitial spaces

Not normal

Imprint thumbs 3-4 sex against ankle malleolus or tibia , if pressure leaves dent “pitting” edema

Question 12

1+

Answer 12

Mild pitting

Slight indentation

No swelling

Question 13

2+

Answer 13

Moderate putting

Indentation subsides rapidly

Question 14

3+

Answer 14

Deep pitting

Indentation remains for short time

Legs look swollen

Question 15

4+

Answer 15

Very deep pitting

Indentation lasts long time

Leg is very swollen

Question 16

Danger signs of skin ABCDE

Answer 16

Asymmetry

Border irregularity

Color variation

Diameter greater than 6mm

Elevation of evolutioni

Question 17

Profile sign

Answer 17

Angle of nail base 160 degrees

Normal 160

Clubbing 180

Question 18

Cyanosis is dark skin individual

Answer 18

Skin dark but dull

Lifeless

Severe: only apparent

Check: conjunctivae, oral mucosa, nail beds

Question 19

Scale lesion

Answer 19

Secondary

Compact

Dedicated flakes of skin

Dry or greasy

Silvery or white
S

Shedding of dead keratin cells

Question 20

Ulcer

Answer 20

Deep depression

Extends into dermis

Irregular shapes

Can bleed

Leaves scar tissue

Question 21

Fissure skin lesion

Answer 21

Secondary

Linear crack

Abrupt edges

Extends into dermis

Dry or moist

Question 22

Erosion lesion

Answer 22

Shallow depression

Superficial

Loss of epidermis

Moist

No bleeding

Does not extend into dermis

Question 23

Keloid scar

Answer 23

Scar tissue beyond sites of injury

Smooth, firm, rubbery, shiny, “clawlike”

Surgery

Acne

Tattoo

Infection

Question 24

Lichenification

Answer 24

Prolonged intense scratching

Thicken skin

Tightly packed set of papules

Looks like moss surface

Question 25

Stage 2 pressure ulcer

Answer 25

Partial thickness skin erosion Loss of epidermis Sometimes dermis Shallow Open blister Pink wound bed

Question 26

Macule

Answer 26

Primary skin lesion Some color change Flat Circumscribed Less than 1cm

Question 27

Papule

Answer 27

Superficial thickening of epidermis

Question 28

Discrete lesion shape

Answer 28

Distinct Lesions remain separate

Question 29

Cyanosis light skin vs dark

Answer 29

White: appears dark blue -reflects unoxygenated blood Dark skin: gray or whitefish around mouth and gray or bluish around conjunctivae (eye lid)

Question 30

Stage 1 pressure ulcer

Answer 30

Skin is intact Some redness

Question 31

Stage 3 pressure ulcer

Answer 31

Full thickness of skin lost Not through underlying fascia Subcutaneous fat shown but not tendon, muscle or bone