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Health and Illness Concepts I Nursing: N1210 > Sensory/Integumentary System (Exam Two) > Flashcards

Sensory/Integumentary System (Exam Two) Flashcards

1
Q

What does the integumentary system consist of?

A
  • Hair
  • Nails
  • Skin
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2
Q

The skin is considered what?

A

An organ

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3
Q

The skin is a barrier against what?

A
  • Germs
  • Pathogens
  • Chemicals
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4
Q

What are the two layers of the skin?

A
  • Epidermis

- Dermis

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5
Q

Which is the outermost layer of skin?

A

Epidermis

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6
Q

What is the hypodermis composed of? What does it do?

A
  • Made up of loose connective tissue and adipose tissue

- Insulates and acts as an energy reservoir

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7
Q

What is the dermis composed of?

A
  • Collagen fibers

- Elastin fibers

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8
Q

What is the function of nose hair?

A

Filter from harmful substances

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9
Q

What is the function of hair on the scalp?

A

Insulation

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10
Q

What is the function of the eyelashes?

A

Protect the eye from dust and sweat

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11
Q

Any break or laceration of the skin puts the patient at an increased risk for what?

A
  • Infection

- Dehydration

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12
Q

Describe the function of the five layers of the epidermis.

A
  • Newest skin at the bottom layer
  • Older skin at the top layer
  • New layers are constantly replacing the old layers
  • Old layers will slough off
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13
Q

What is the skins function in relation to water?

A
  • Keeps large amounts of water from exiting the body

- Keeps large amounts of water from entering the body

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14
Q

What gives the skin and the hair its color?

A

Melanocytes

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15
Q

What are three primary functions of the epithelium (skin)?

A
  • Prevents too much water from entering/exiting the body
  • Intact skin protects against infection
  • Contains sensory receptors
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16
Q

What role do blood vessels play in relation to the skin?

A
  • Provide tissue nourishment

- Regulate temperature

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17
Q

List the two types of sweat glands.

A
  • Apocrine

- Eccrine

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18
Q

Where are apocrine glands located?

A
  • Axillary (armpit)

- Groin

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19
Q

Where are eccrine glands located?

A

Rest of the body (where apocrine glands are not)

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20
Q

How much water is lost through the eccrine glands per day? What type of loss is this?

A
  • 500mL

- Insensible loss

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21
Q

What are sebaceous glands responsible for? What type of substance is sebaceous glands?

A
  • Prevents the hair and skin from drying out

- Oily

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22
Q

Why does hair become gray and thin in the older adult population?

A
  • Melanocytes die off

- Inactive hair follicles

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23
Q

The skin of older adults is more prone to what?

A
  • Skin breakdown

- Poor wound healing

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24
Q

Slowed skin turgor is an indication of what?

A

Dehydration

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25
Q

Where should skin turgor be assessed on an older adult?

A
  • Clavicle
  • Shoulder
  • Sternum
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26
Q

What is pallor? Where is pallor assessed?

A
  • Pale skin

- Mucus membranes, lips, nail beds

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27
Q

What is erythema?

A

Redness of the skin

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28
Q

What is jaundice? Where is jaundice assessed?

A
  • Yellow or orange discoloration of skin

- Oral mucosa, sclerae

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29
Q

What is cyanosis? Where is cyanosis assessed?

A
  • Bluish discoloration of the skin

- Nail beds, palms, soles of feet

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30
Q

Brown discoloration of the skin may result from what? Where is this most common?

A
  • Chronic peripheral vascular disease

- Lower legs

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31
Q

Skin inspection varies based on what?

A

Ethnicity or skin color

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32
Q

What ethnicity already has a bluish tint to the lips?

A

Mediterranean descent

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33
Q

What is a primary lesion?

A

Initial reaction to the disease process

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34
Q

What is a secondary lesion?

A

Changes that take place in primary lesion itself

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35
Q

Describe the characteristics of vesicles?

A
  • Up to 1cm in diameter
  • Blister-like appearance
  • Contain serous fluid
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36
Q

List examples of vesicles?

A
  • Poison ivy
  • Shingles
  • Chicken pox
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37
Q

Describe the characteristics of papules?

A
  • 1cm in diameter

- Solid, raised

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38
Q

List examples of papules?

A
  • Mole

- Wart

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39
Q

Describe the characteristics of a wheal?

A
  • Insect bite appearance
  • Round, elevated
  • White in center
  • Redness on outer edges
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40
Q

What are examples of a wheal?

A
  • Hive

- Mosquito bite

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41
Q

What is lichenification? What type of patients might suffer from lichenification?

A
  • Thickening and hardening of the skin

- Wheelchair bound patients

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42
Q

List the two vascular markings.

A
  • Petechiae

- Ecchymosis

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43
Q

What is petechiae? Where is petechiae best assessed in a patient with darker skin?

A
  • Reddish purple hemorrhagic spots

- Oral mucosa

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44
Q

What is ecchymosis?

A

Bruising

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45
Q

Bruises in different stages of healing may indicate what?

A

Abuse

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46
Q

Which portion of the hand is used to assess skin temperature?

A

Posterior surface

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47
Q

Describe 4+ pitting edema.

A
  • Severe
  • 8mm depression
  • Can last more than 2 minutes
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48
Q

What does 0 indicate on the pitting edema scale?

A

No edema present

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49
Q

What is alopecia?

A

Hair loss

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50
Q

Excessive facial hair in females is associated with what disease?

A

PCOS

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51
Q

Hair thinning is associated with what disease?

A
  • Hypothyroidism

- Cushing’s

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52
Q

What nail abnormality is associated with hypoxia?

A

Clubbing

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53
Q

What nail abnormality is associated with anemia?

A

Spoon nails

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54
Q

What nail abnormality is associated with fungal infections?

A

Thick nails

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55
Q

What is Beau’s lines?

A

Transverse depressions of the nails

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56
Q

What are the three different types of skin biopsies?

A
  • Punch
  • Shave
  • Excisional
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57
Q

What is Wood’s lamp? What skin disease does it assess for?

A
  • UV rays to detect fluorescent materials in skin/hair

- Assess’s for ringworm

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58
Q

Positive scratch test is indicated by what?

A

Wheal

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59
Q

The nurse should ensure which materials are in the room during a scratch test?

A

Crash cart

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60
Q

What is balneotherapy?

A

Therapeutic bath

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61
Q

Powders should be avoided in patients who have what type of problem?

A

Respiratory problems

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62
Q

What can a topical steroid medication cause?

A

Thinning of the skin

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63
Q

Why are newborns more prone to skin infections within the first week of life?

A

Due to more alkaline or basic skin integrity

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64
Q

Who is at a higher risk for skin cancer?

A

Caucasians

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65
Q

What are pressure ulcers?

A

Tissue anoxia due to pressure against the skin

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66
Q

What can cause pressure ulcers?

A
  • Pressure
  • Friction
  • Shear
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67
Q

The nurse should never massage _____ _____.

A

Reddened areas

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68
Q

List prevention methods for pressure ulcers?

A
  • Clean
  • Dry
  • Clean incontinence areas promptly
  • Turn/reposition every two hours
  • Provide adequate nutrition/hydration
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69
Q

What is included on the Braden Scale?

A
  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and Shear
70
Q

What is considered a minimal risk score on the Braden Scale?

71
Q

What is considered a moderate risk score on the Braden Scale?

72
Q

What is considered a high risk score on the Braden Scale?

73
Q

What is considered a very high risk score on the Braden Scale?

A

9 or below

74
Q

How often should the Braden Assessment be conducted?

A

Once every shift

75
Q

What does black skin indicate?

76
Q

What does yellow skin indicate?

A

Infection or slough

77
Q

What does red skin indicate?

78
Q

What does pale pink skin indicate?

A

Poor blood supply or blood circulation

79
Q

What is debridement?

A

Removal of dead tissue

80
Q

List the different types of debridement.

A
  • Mechanical
  • Enzymatic
  • Autolytic
  • Surgical
81
Q

What is mechanical debridement?

A

Scissors and forceps

82
Q

What is enzymatic debridement?

A

Topical enzyme agent

83
Q

What must be avoided with enzymatic debridement?

A

Healthy tissue

84
Q

What is autolytic debridement?

A
  • Dressing over wound

- Natural enzymes break down eschar

85
Q

Autolytic debridement cannot be used on what type of wounds?

A

Infected wounds

86
Q

What is the nurses role regarding a therapy wound vac?

A

Management and troubleshooting of the machine

87
Q

What should the nurse be cautious of in regard to wound care?

A
  • Tape

- Moisture

88
Q

What is stage one of a pressure ulcer?

A

Skin is intact

89
Q

What is stage two of a pressure ulcer?

A

Break in skin

90
Q

What is stage three of a pressure ulcer?

A

Visible subcutaneous tissue

91
Q

What is stage four of a pressure ulcer?

A

Visible muscle, tendon, or bone

92
Q

What is considered an unstageable pressure ulcer?

A
  • Covered with eschar or slough

- Not visible to assess

93
Q

What is a deep tissue injury? What might indicate a deep tissue injury?

A
  • Damaged or dead tissue that does not have a break in the skin
  • Indicated by a large bruise that does not have a cause
94
Q

What is dermatitis?

A

Inflammatory skin disorder

95
Q

What are the signs and symptoms of dermatitis?

A
  • Itching
  • Redness
  • Skin lesions with varying borders/distribution patterns
96
Q

Do pressure ulcers decrease in stages? How are they described?

A
  • No

- They are described by the diagnosed stage and stage of healing (i.e. stage 3 - healed/healing)

97
Q

What is an example of atopic dermatitis?

98
Q

What are the signs and symptoms of eczema?

A
  • Dry skin
  • Pruritic (itchy)
  • Exacerbation with serous fluid
  • Remission and flare ups
99
Q

What education should the nurse provide to a patient with eczema?

A
  • Avoid fragrances
  • Pat dry
  • Avoid harsh soaps and added oils
  • Soft, loose fitting clothes
  • No fabric softener
100
Q

What population is prone to eczema?

A
  • Infants

- Young children

101
Q

What is contact dermatitis?

A

Direct contact with irritant or allergen

102
Q

What are the two types of contact dermatitis?

A
  • Immunological (allergen)

- Non-immunological (irritant)

103
Q

What are examples of immunological contact dermatitis?

A
  • Nickel
  • Poison ivy
  • Poison oak
104
Q

What are examples of non-immunological contact dermatitis?

A
  • Diaper dermatitis/rash

- Contact with feces, urine, harsh detergents, friction

105
Q

What education should the nurse provide to the parents of an infant with recurrent diaper rash?

A
  • Frequent diaper changes
  • No harsh detergents
  • Avoid wipes with chemicals
  • Air out affected area
  • Mild soaps
  • Barrier creams
106
Q

What is seborrheic dermatitis?

A
  • Increased sebum production

- Yeast overgrowth

107
Q

Give an example of seborrheic dermatitis?

A

Cradle cap

108
Q

What are the possible complications of dermatitis?

A
  • Infection

- Sepsis

109
Q

When is infection likely to occur with deramtitis?

A

With scratching

110
Q

List the steroid medications commonly used for dermatitis?

A
  • Hydrocortisone

- Methylprednisolone

111
Q

What is psoriasis? How does psoriasis present on the skin?

A
  • Proliferation of epidermal cells at a rapid rate
  • Overgrowth of skin
  • Scaling
112
Q

What are the signs and symptoms of psoriasis?

A
  • Silvery/White scales
  • Papules
  • Plaques
  • Itching
113
Q

What are the complications of psoriasis?

A
  • Secondary infection
  • Arthritis
  • Nail changes
  • Lymphadenopathy
114
Q

What medications can be used in a patient with psoriasis?

A
  • Topical corticosteroids
  • Vitamin D
  • Enbrel
  • Methotrexate
115
Q

When is methotrexate used for psoriasis patients?

A

Extreme cases

116
Q

When can methotrexate not be used?

A

During pregnancy

117
Q

What are the visual characteristics of impetigo?

A

Vesicles followed by honey colored crust

118
Q

When is impetigo no longer contagious?

A

When lesions crust over

119
Q

What is a furuncle?

A
  • Small, tender boil

- Occurs in one or more hair follicles

120
Q

Where on the body are furuncle’s common?

A
  • Areas prone to perspiration
  • Buttocks
  • Axillae
121
Q

What is a carbuncle?

A
  • Abscess

- Deeper than a furuncle

122
Q

Where on the body are carbuncles located?

A
  • Areas where skin is thick
  • Back of neck
  • Upper neck
  • Buttocks
123
Q

Furuncles and carbuncles are both caused by what kind of bacteria?

124
Q

What are the two types of herpes simplex virus?

A
  • HSV1 (fever blister)

- HSV2 (genital herpes)

125
Q

When does herpes reoccur?

A

With stress

126
Q

What is herpes zoster?

A
  • Acute inflammatory infection

- Follows a nerve distribution

127
Q

Give an example of herpes zoster?

128
Q

What causes herpes zoster?

A

Reactivation of chickenpox virus

129
Q

Shingles are _____ to one general side or area.

130
Q

What are the prevention methods for shingles?

A
  • Varicella Vaccine (Varivax)

- Zostavax

131
Q

What is the primary nursing intervention for shingles?

A

Pain management

132
Q

Ophthalmic herpes zoster affects which cranial nerve?

A

Cranial nerve V (5)

133
Q

What medication can be administered for shingles? When is it most effective?

A
  • Acyclovir

- Within 72 hours of onset of rash

134
Q

What medications might be associated with nerve pain?

A
  • Anticonvulsants

- Antidepressants

135
Q

What causes tinea(s)?

A

Dermatophytes

136
Q

What action should the nurse perform first in regards to cellulitis?

A

Draw a border around it

137
Q

What is the most common cause of cellulitis?

A

Open wounds

138
Q

Infections affecting the face may possibly spread to what other area?

139
Q

What is acne vulgaris?

A

Increased sebum production

140
Q

Where does acne vulgaris usually occur?

A
  • Face
  • Back
  • Chest
  • Shoulders
141
Q

What are the two times of comedones?

A
  • Open

- Closed

142
Q

What are open comedones?

A

Blackheads

143
Q

What are closed comedones?

A

Whiteheads

144
Q

What is pediculosis?

145
Q

What are the signs and symptoms of pediculosis?

A
  • Itching
  • Papular rash
  • Teardrop shaped masses (nits)
146
Q

Pediculosides cannot be used on what ages?

A

Children under 2

147
Q

What are scabies?

A

Mites that burrow into the skin

148
Q

What are the signs and symptoms of scabies?

A
  • Elevated short, wavy lines
  • Itching
  • Rash
149
Q

What must be done in order for scabies to be diagnosed?

A

Must be viewed under microscope

150
Q

How long might itching continue after treatment of scabies?

151
Q

What is pemphigus?

A
  • Autoimmune disorder

- Fluid filled lesions on skin and mucous membranes

152
Q

What are the triggers of pemphigus?

A
  • Sun
  • Certain drugs
  • Certain food
153
Q

Cancer arising from the basal cell layer is known as what?

A

Basal Cell Carcinoma

154
Q

Cancer arising from the epidermis is known as what?

A

Squamous Cell Carcinoma

155
Q

Cancer arising from the menalocytes is known as what? This cancer is highly what?

A
  • Malignant Melanoma

- Highly metastatic

156
Q

What are the three different types of malignant melanoma?

A
  • Lentigo
  • Superficial spreading
  • Nodular
157
Q

Which type of malignant melanoma is the most common?

A

Superficial spreading

158
Q

Describe nodular malignant melanoma.

A
  • Occurs suddenly
  • Blue-black//blue-gray/reddish blue in color
  • Lesions are fragile and bleed easily
159
Q

Which is the most dangerous form of malignant melanoma? Why?

A
  • Nodular

- Rapid growth and spreading

160
Q

What is the most significant risk factor for developing skin cancer?

A

-Ultraviolet light/rays

161
Q

How is skin cancer prevented?

A
  • Limit exposure to UV rays
  • Use sunscreen
  • Wear protective clothing
  • Report changes in moles
162
Q

The nurse should educate the patient avoid the sunlight exposure during what time frame?

A

10AM to 4PM

163
Q

What is a cyst?

A
  • Saclike growth

- Contains something inside

164
Q

What is a keloid?

A

Overgrowth of tissue during scar formation

165
Q

What is pigmented nevus?

166
Q

What is verrucae?

A
  • Warts

- Viral infection by direct skin contact

167
Q

Where do verrucae usually appear?

A
  • Hands
  • Fingers
  • Feet
168
Q

What is the cause of verrucae? When does it usually occur?

A
  • Caused by HPV

- Occurs during childhood or adolescents

169
Q

What percent of warts will go away on their own?

A

2/3 of warts will go away on their own within two years

170
Q

The nurse should educate the patient on what in regard to moles?

A

Report changes in moles

Health and Illness Concepts I Nursing: N1210 (12 decks)

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