Health assessment-test 2-skin, hair, nails

Question 1

What can skin clue you in to?

Answer 1

respiratory problems
cardiac problems
dehydration

Question 2

What are the respiratory signs

Answer 2

pallor
cyanosis
clubbing
decreased capillary refill

Question 3

Define pallor

Answer 3

pale: can occur with high stress like anxiety or fear; also from vasoconstriction from exposure to cold and from cigarette smoking and in the presence of edema

Question 4

Define cyanosis

Answer 4

blue or purple discoloration due to decreased perfusion; not always a reliable indicator

Question 5

Where is cyanosis best seen?

Answer 5

lips, nose, cheeks, ears, and oral mucous membranes

Question 6

True or false: cyanosis is an early sign of respiratory distress.

Answer 6

false; it is a late sign

Question 7

If hemoglobin is ___ ___, it is impossible to become cyanotic

Answer 7

< 5

Question 8

some people _____ turn cyanotic. Why?

Answer 8

never; if not enough RBC, can’t turn blue

Question 9

Clubbing is the _____ of _____ fingers and ____ ____

Answer 9

bulging
distal
nail beds

Question 10

In clubbing, nail beds have a _____ feeling.

Answer 10

spongy; moves alot when fingernail is moved up and down

Question 11

What kind of disorders is clubbing associated with?

Answer 11

pulmonary, cardia, neoplasms (chronic lung inflammation, bronchial tumors, congenital cyanotic heart disease, lung cancer, pulmonary disease)

Question 12

Normal nail is ___ degrees. Early clubbing, the angle straightens to ____ degrees.

Answer 12

160 degrees or less

180 degrees

Question 13

Capillary refill…
Sluggish return means?
Early and late signs?

Answer 13

color should return within 2 seconds
sluggish return indicates respiratory or cardiac dysfunction
Pale (early)
Blue (late)

Question 14

How do you check for clubbing?

Answer 14

place fingers nail to nail; if you see a diamond there is no clubbing

Question 15

Can clubbing be reversed?

Answer 15

yes, if the problem can be fixed. In cystic fibrosis, clubbing will not go away

Question 16

GCR stands for what in documentation?

Answer 16

Good capillary refill

Question 17

Cardiac signs include:

Answer 17

Pallor
poor capillary refill
clubbing
cyanotic
temperature (cool)
diaphoresis (sweating--skin not perfusing)
edema

Question 18

Edema is caused by:

Answer 18

fluid accumulation in the interstitial spaces of dependent areas (feet, ankles, sacrum)

Question 19

How do you check for edema?

Answer 19

press firmly for 3-4 seconds on tibia or ankle malleolus

Question 20

Bilateral edema can indicate…

Answer 20

heart or kidney failure (one side may be an injury)

Question 21

Edema scale
1+
2+
3+
4+

Answer 21

1+ Mild pitting (slight indentation, no perceptible swelling of the leg)
2+ Moderate pitting (indentation subsides rapidly)
3+ Deep pitting (indentation remains for a short time; leg looks swollen)
4+ Very deep pitting (indentation lasts a long time; leg is very swollen)

Question 22

dehydration signs:

Answer 22

dry mucous membranes (in mouth, membranes look dry, dull) Normal is smooth and moist.
poor skin turgor

Question 23

Skin turgor can be assessed best…

Answer 23

under the clavicle for adults; in infants, assess the abdomen

Question 24

What should skin turgor be like if it is normal?

Answer 24

mobile and return quickly when released

Question 25

Scleroderma

Answer 25

arm and leg area feel like a cast, very hard

Question 26

Jaundice

Answer 26

Yellowish skin color

Question 27

Where is jaundice first noted?

Answer 27

at the junction of the hard and soft palate and the sclera

Question 28

What is jaundice associated with?

Answer 28

liver dysfunction and | some blood disorders (sickle cell dz)

Question 29

Malignant skin lesions graded by what scale?

Answer 29

``` A = Assemetry B = border irregularity C = Color variation (don't want variation; one color) D = diameter > 6 mm E = elevation or evolution (growing or changing) ```

Question 30

Cafe au lait

Answer 30

tan to light brown, irregular shape, oval patch with well-defined borders (some diseases related to) caused by increased melanin pigment in basal cell layer

Question 31

Lesions have common shapes/configurations. | Name four:

Answer 31

Confluent--lesions run together (hives) Discrete--distinct, individual lesions that remain separate (skin tags, acne) Target--or iris; round shape center is different color; resembles iris of eye, concentric rings of color in lesions (erythema multiforme) Zosteriform--linear arrangement along a unilateral nerve route (herpes zoster)

Question 32

Macule

Answer 32

freckle/flat mole; darker color; less than 1 cm (freckles, flat nevi, measles, scarlet fever)

Question 33

papule

Answer 33

something you can feel; solid, elevated, circumscribed; less than 1 cm (mole, wart)--you can palpate a papule

Question 34

nodule

Answer 34

solid, elevated, hard or soft, larger than 1 cm; may extend deeper into dermis than papule (fibroma)

Question 35

tumor

Answer 35

larger than a few cm; firm or soft; can be benign (lipoma, hemangioma)

Question 36

vesicle

Answer 36

elevated cavity containing free fluid; up to 1 cm (herpes, chicken pox (early), shingles)

Question 37

uticaria (hives)

Answer 37

wheals coalesce to form extensive reaction; intensely pruritic

Question 38

wheal

Answer 38

superficial, raised, transient and erythematous; slightly irregular shape from edema (mosquito bite, allergic reaction)

Question 39

crust

Answer 39

thickened, dried out exudate left when vesicles/pustules burst or dry up; can be red-brown, honey or yellow

Question 40

erythema

Answer 40

redness of the skin

Question 41

lesion

Answer 41

any abnormality of skin

Question 42

Four stages of pressure ulcers | **TEST QUESTION**

Answer 42

Stage 1: intact skin; appears red, not broken; will usually heal Stage 2: skin breaks; shallow; looks like open blister or abrasion Stage 3: ulcer extends into subcutaneous tissue and resembles crater (won't see muscle, bone or tendon, but may see fat) Stage 4: involves all skin layers; exposes bone, muscle, tendon; no pain because nerves are dead

Question 43

Where do adults and children normally get pressure ulcers

Answer 43

elbows, sacrum, bones of bottom...anywhere with bone-y prominences Babies-- get pressure ulcers from medical equipment

Question 44

pattern injury

Answer 44

bruise or wound whose shape suggests the instrument or weapon that caused it (can suggest child abuse)

Question 45

bruise

Answer 45

mechanical injury resulting in hemorrhage into tissues; skin intact; ranges in color

Question 46

petechiae

Answer 46

bleeding from superficial capillaries; can tell if this is blood is by pressing on it. If it does not turn white then you know it is petechiae (can use a glass to look thru to see)

Question 47

ecchymosis

Answer 47

purplish patch resulting from extravasation of blood into skin; >3mm

Question 48

psoriasis

Answer 48

scaly, erythematous patch with silvery scales on top