Quiz 3 Flashcards
How can the attachment at base of a skin lesion be described?
pedunculated - having a salk
sessile - without a stalk
What will show an annular configuration?
fungal infection (perfect circle)
What are the findings for skin elasticity (turgor)?
tenting = dehydrated
taut = overhydrated
Where should one assess for edema?
feet, ankles, sacrum
(dependent areas)
Describe pitting edema vs non-pitting edema
pitting
- indentation
- myxedema coma: consequences of hypothyroidism - can’t break down carbs
non-pitting
- no indentation
- lymphedema: issues with lymphatic flow
What are the types of lesions?
primary
- develop on unaltered skin due to irritation/disease
- mole, plaque, nodules, blisters
secondary
- existing primary lesions that change over time
- scars, ulcerations, abrasions
vascular
- hemangiomas, ecchymosis, petechiae, hematoma
What can be seen from a scalp and hair assessment?
folliculitis - seen in homeless
tinea capitis - ringworm, lighter than rest of skin, seen in school age children
lice
What medication is used to treat lice?
permethrin
What are the isolation precautions for lice?
contact precautions
gown
gloves
hairnet
booties
What are expected findings of the assessment of nails?
hygiene
even pink undertone
cap refill time < 3 secs
What is the result of an injury to the nail?
subungual hematoma
What is the difference between melanonychia and subungual melanoma? How can a nurse classify this?
melanonychia - mole under nail
subungual melanoma - mole turning into cancer, thicker bleeds into finger
even if nurse thinks its melanoma, nurse can’t dx, so put melanonychia
What is a hemangioma?
cluster of immature capillaries
seen in newborns/older adults
What is a port wine stain?
permanent flat irregular shaped lesion
ranges in color from pale red to deep purple
color deepens with exertion, emotion, temperature
What is ecchymosis?
bruising
What is the difference between vesicles and bullae?
vesicles (viral)
- smaller
- herpes simplex/zoster, early chickenpox
bullae (burns)
- contact dermatitis, blisters
What is a wheal?
elevated
red
caused by diffuse fluid in tissues
ex: insect bites, hives
Describe a stage 1 pressure ulcer
non-blanchable
local erythema
Describe a stage 2 pressure ulcer
partial thickness loss
blister that pops
Describe a stage 3 pressure ulcer
full thickness loss
subcutaneous fat can be seen, but no tendon or bone
Describe a stage 4 pressure ulcer
full thickness loss
bone, tendon, or muscle can be seen
Describe a deep tissue injury
surface skin intact, but damage underneath
caused by medical devices
Describe an unstageable ulcer
covering eschar or slough prevent knowing true depth
How can a malignant melanoma be described?
ABCDE
asymmetry
border
color
diameter
evolution
What can cause facial drooping?
MG
stroke
What accessory structures in the eye lubricates?
meibomian glands
lacrimal apparatus
What can be noted with an ophthalmoscope?
red reflex - reflection of light reaches the back of the eye
What are the expected assessment finding of the bulbar conjunctiva?
white
moist
What are the expected assessment finding of the palpebral conjunctiva?
pink
moist
vascular
What are abnormal findings of the eyelid?
xanthelasma - hypercholesterolemia
ptosis
hordeolum (stye) - oil gland infected
chalazion - oil gland blocked
blepharitis - staph inf. - eyes can’t close
What is cranial nerve VIII How can cranial nerve VIII be tested?
vestibulocochlear nerve - controls equilibrium
romberg test
whisper test
What are the techniques for assessing the ear, nose, mouth, and throat?
inspection
palpation
percussion
transillumination
What will the palpation of the tagus and the mastoid process indicate?
otitis media (ear infection)
tenderness
What is an expected finding of the tympanic membrane?
pearly gray w/ cone of light and process of malleus
Describe a retracted tympanic membrane
negative pressure in the middle ear from obstructed Eustachian tube or chronic otitis media
What is a tympanostomy tube?
tube placed on tympanic membrae to drain fluid that is behind it
What will a weber test indicate?
screens for hearing loss
tuning fork placed on top of head
conductive loss = sound heard in bad ear
sensorineural loss = sound heard in good ear
What will a rinne test indicate?
screens for hearing loss
tuning fork placed on mastoid process (bone conduction) - wait until sound goes away - place in front of ear (air conduction)
bone>air = conductive loss
air>bone = sensorineural loss
What can be seen in the skin folds that suggests hyperinsulinemia?
acanthosis nigricans
Describe the assessment of the thyroid
palpation: supple or non-palpable
auscultation: no bruits (bruits = hyperthyroidism)
What is hyperthyroidism?
grave’s disease
excessive T3 and T4
exophthalmos (expected finding)periorbital edema
What is the difference between thyroid adenoma and thyroid carcinoma?
adenoma: tumor occupying space (localized)
carcinoma: tumor looks for lymph nodes (spread)
What medications are used to treat hyperthyroidism?
PTU
methamyzole
