Skin, Hair, & Nails

Question 1

What two mechanisms can cause pallor?

Answer 1

Loss of oxygenated hemoglobin

Vasoconstriction

Question 2

How might pallor appear in a brown-skinned individual?

Answer 2

yellowish-brown

Question 3

How might pallor appear in a black-skinned individual?

Answer 3

ashen or gray

Question 4

According to Schamorth, what are some other potential causes of clubbing?

Answer 4

congenital cyanotic heart disease
lung cancer
pulmonary diseases

Question 5

Is clubbing a permanent change or can it resolve?

Answer 5

in most cases not all-depends on the condition

Question 6

When checking capillary refill, how quickly should color return to the nail bed?

Answer 6

1-2 secs

Question 7

How do you assess capillary refill if the client has on nail polish?

Answer 7

check the anterior side of the finger

Question 8

When checking capillary refill, how many fingers/toes should the nurse check?

Answer 8

at least one on each extremity

Question 9

Edema is caused by a buildup of fluid in the _____ spaces.

Answer 9

interstitial

Question 10

What kind of heart failure is associated w/ peripheral edema?

Answer 10

right sided

Question 11

If a patient is bedridden, edema might occur in what other body part?

Answer 11

sacrum

Question 12

Where’s a good place to assess skin turgor on an adult?

Answer 12

anterior chest under clavicle

over the abdomen (infant)

Question 13

What would an abnormal skin turgor test look like?

Answer 13

pinched skin recedes slowly or “tents” & stands by itself

Question 14

If your client has poor skin turgor, what might that mean?

Answer 14

dehydration

Question 15

Jaundice occurs when there are rising amounts of ______ in the blood.

Answer 15

bilirubin

Question 16

If someone is jaundiced, what might his or her stools and urine look like?

Answer 16

clay-colored stools

dark golden urine