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NSG 1100 > Unit IV (Physical Integrity) > Flashcards

Unit IV (Physical Integrity) Flashcards

1
Q

A lesion that appears as the initial result of changes in the skin is termed:

A

Primary Lesion

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2
Q

Lesions that do not appear initially as a result to the change of the skin are termed:

A

Secondary Lesion

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3
Q

How are secondary lesions formed?

A

Result from trauma or infection of the primary lesion.

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4
Q

True/False:

All lesions are external.

A

False, lesions may be external or internal.

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5
Q

A break in the continuity of the skin is termed:

A

wound.

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6
Q

What does the nurse assess a wound for?

A

shape, size, depth, location, presence of drainage, odor.

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7
Q

The patient has a surgical incision. The nurse identifies this type of wound to be:

A

Intentional.

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8
Q

The patient has a wound from a car accident. The nurse identifies this type of wound to be:

A

Unintentional.

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9
Q

What type of wound is an ecchymosis?

A

Closed wound.

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10
Q

Define a closed wound.

A

Skin does not open, but trauma is present to underlying tissues.
Results of a force, blow, or strain

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11
Q

The patient has a pin-point wound on their skin from accupuncture. Is this wound type intentional or unintentional?

A

Intentional.

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12
Q

What is another term for ecchymosis?

A

Bruise

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13
Q

A primary wound that results from cutting with an instrument is termed:

A

Incision

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14
Q

A superficial wound resulting from scraping or rubbing is termed:

A

abrasion

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15
Q

Skin that has torn with irregular and ragged edges is termed:

A

laceration.

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16
Q

What chemical is primarily responsible for skin tone?

A

Melanin

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17
Q

The nurse notes the patient to be pale. How is this charted?

A

Pallor

18
Q

The nurse receives report that the patients skin is flush. What does the nurse expect to see? What causes flushing?

A

Redness of the skin, associated wit increased body temperatures. Caused by vasodilation.

19
Q

What skin condition/coloration would the nurse expect to see in a patient who has extremely inadequate tissue perfusion?

A

Cyanosis

20
Q

This skin condition/discoloration is caused by an increase of bilirubin in the blood.

A

Jaundice.

21
Q

Other than increased bilirubin in the blood, what does jaundice indicate is happening in the patients body?

A

Liver disease or blocked bile ducts.

22
Q

What assessment scale is used to assess pressure ulcers?

A

Braden Scale

23
Q

What six aspects does the Braden Scale assess?

A 
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction/Shearing
24
Q

What Braden Scale score indicates risk for pressure sores?

A

A score less than 18 is considered at risk for pressure sores. (Lower the number, the higher the risk)

25
Q

What causes pressure ulcers?

A

Unrelieved pressure that leads to decreased circulation and damage of tissues.

26
Q

What factors relate to the development of pressure ulcers? (Not Braden Scale)

A

Pressure Intensity
Pressure duration
Tissue Tolerance

27
Q

The nurse assess the patients shoulder to have non-blanching reddness, and the skin is entirely intact. What stage is this?

A

Stage 1

28
Q

The nurse assesses the patients leg to have partial skin loss involving the epidermis and dermis. What stage is this?

A

Stage 2 (looks like abrasion, blister, or shallow crater caused by rubbing or scrapping)

29
Q

The nurse notes extensive loss of skin, and tissue necrosis. Muscle and bone is visible. What stage is this?

A

Stage 4

30
Q

The nurse notes the patients skin to look like a deep crater involving loss, damage, or necrosis of subcutaneous tissue. What stage is this?

A

Stage 3

31
Q

Name 4 skin conditions noted for geriatric patients. Define each condition.

A

Keratosis- overgrowth and thickening of epithelium
Lentigo Senilus- Age Spots (brown macula)
Skin Tags- flesh colored, raised areas
Skin Tears- Thin layer of skin in elderly is easily damaged.

32
Q

What increases in regards to hair for geriatric pyhsical integrity changes?

A

Graying/whiting
Thinning
Eyebrow, ear and nasal hair coarser and longer.
Coarse facial hair in women.

33
Q

A wound in which a sharp instrument penetrates the skin and underlying tissue

A

Puncture

34
Q

Normal ranges of skin color

A

Pinkish white-shades of brown

35
Q

Jaundice is primarily seen where on the body

A

Skin

Sclera of eye

36
Q

Define tissue ischemia

A

Localized absence of blood and oxygen to tissue cells

37
Q

A wound in which a sharp instrument penetrates the skin and underlying tissue

A

Puncture

38
Q

Normal ranges of skin color

A

Pinkish white-shades of brown

39
Q

Jaundice is primarily seen where on the body

A

Skin

Sclera of eye

40
Q

Define tissue ischemia

A

Localized absence of blood and oxygen to tissue cells

NSG 1100 (22 decks)

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