Health Assessment Quiz 2 Flashcards
What are the primary assessment tools used to examine the hair, skin, and nails?
inspection and palpation
When palpating the nails the surface should feel:
smooth, firm, and uniform
A patient has pink nail beds/color. A nurse would say these nails are:
normal
Yellow nails may indicate
psoriasis, fungal infection, chronic respiratory disease, or tobacco use
A patient has blue nail beds/color. A nurse may conclude this patient has:
acute cyanosis
Normal nail plates:
should be smooth and slightly convex
During an assessment a nurse finds her patient has clubbed finger nails. The nurse will want to test for:
chronic hypoxia
The laymen’s term for koilonychia is:
spoon shaped nails
Define paronychia:
a bacterial infection of tissue surrounding the nail
T or F: If a patient presents with paronychia a nurse may want to suggest a course of antibiotics.
TRUE
Define Onychomycosis:
fungal infection of the nail bed
The main point when it comes to hair assessment is watching for changes in:
hair texture, quantity, and distribution
T or F: Alopecia may be considered normal for some men.
TRUE. Alopecia refers to hair loss, which is normal for older men who go bald
When assessing the scalp of a 8 year old, what is one important thing to check for?
the presence of lice infestation
The scalp should be:
smooth and nontender
The skin has three primary layers which are:
Epidermis, dermis, hypodermis
The epidermis is:
the thick outer layer of the skin
This layer of the skin contains blood, lymphatic cells, nerves, base of hair follicles, sebaceous and sweat glands, collagen and reticular fibers
the dermis
This layer of the skin is connected to underlying organs, contains adipose for cushioning organs
hypodermis
A nurse bundles a newborn baby in a blanket to keep the child warm. In terms of newborn skin state, why is this important?
babies have very little subcutaneous fat
During different life stages, what body element is attributed with changing the appearance of skin?
hormones
When performing a subjective skin assessment, what factor is important to consider?
Age of the patient
A blister would be an example of a ______________ lesion.
vesicular
This type of lesion is elevate, solid, and measures less than 0.5 cm
papular lesion
Freckles, measles, and some drug rashes are examples of this type of lesion:
macular lesion
Skin turgor, temperature, and moisture level can be used to asses:
dehydration
Circulation of _______ and ________ are most vulnerable.
palms and feet
A lesion would be considered primary if:
it is the initial spontaneous eruption of the lesion.
A secondary lesion is one that:
often occurs afater primary lesion
A nurse sees an essentially flat colored lesion when examining a patient. She would document this as a:
macular lesion
A rash that is firm or filled with solid material is:
a papular rash
A nurse sees a rash that is a combination of papules and patches of flat colored skin. She would document a:
maculopapular rash
A hyperpigmented patch of skin will appear:
dark brown
A hypopigmented patch of skin appears:
white
A mother states her child was just stung by a bee. A nurse would be looking at the child’s skin for:
a wheal rash
What is a wheal rash?
an elevated irregular accumulation of subcutaneous edema
If a section of skin stays discolored for > 30 minutes after relief of pressure it could be described as a:
stage I pressure ulcer
A pressure ulcer that has partial thickness, loss of dermis, open, shallow with a red/pink wound bed would be considered:
Stage II
A pressure ulcer which appears as a deep crater, but the nderlying bone is not present would be considered
Stage III
A nurse notices a wound that has caused extensive destruction, slough/eschar are present, and bone is visible. She would document this as:
a stage IV pressure ulcer
When assessing the head and neck what are the 6 key areas to address?
Head, eyes, ears, nose, mouth and pharynx, neck
HEENT stands for:
Head, Eyes, Ears, Nose, Throat
What are some common ailments related to the HEENT exam?
headache, rhinitis (common cold), sore throat, swollen lymph nodes
T or F: It is normal for babies to have fontanels that are not fused.
TRUE
A nurse can tell a lot about a person’s _____________ health from looking at their eyes.
Emotional health
When assessing the eyes it is important to ask:
any current vision changes, history of visual problems, use of correction lenses?
When performing an eye exam, tell patient to report at any time if:
They have blurred vision, double vision, or see flashes of light (scotomata-blind spots)
The conjunctiva should be obsered for:
erythema or discharge
A nurse is trying to assess a patient for jaundice. How would she do this by looking at the eyes?
looking for yellowing of the sclera
The common term for conjuntivitis is:
pink eye
Erythema on the conjunctiva could be due to a.virus b. bacteria c. trauma d. allergies/irritants e. all of the above
e-all of the above
