Week #1 Concept Review

Question 1

What are the four basic techniques of physical assessment?

Answer 1

Inspection, Percussion, Palpation, and Auscultation

Question 2

What technique is used initially in any physical assessment?

Answer 2

Inspection technique

Question 3

What is the tool used for auscultation? What are the diaphragm and the bell used for?

Answer 3

A stethoscope, the diaphragm is used for high-pitched sounds that includes the lungs, the bell is used for low pitched sounds like Bruits and Cardiac Murmurs

Question 4

What tools are used to assess during percussion? Name two-techniques and when they are used?

Answer 4

The use of the middle fingertips of the dominant hand, may be direct or indirect. Indirect assesses the lung tissue. Direct assesses; nasal congestion or sinus headache.

Question 5

What is blunt percussion? Provide an example?

Answer 5

A type of percussion using the palm of the non-dominant hand flat over the CVA (Costovertebral Angle) of body area, the tapper is the closed fist of the dominant hand.
An example would be the assessment of a kidney injury when there is a hematoma noted at the CVA.

Question 6

What tools are used during palpation? Provide an example of what can be assessed?

Answer 6

The finger pads and/ or metacarpophalangeal joint or ulnar part of the hand. An example, tactile fremitus (ask the patient to state 99, assess placements bilaterally).

Question 7

What is the best technique to assess the lymph nodes?

Answer 7

Gentle circular motions

Question 8

What is the best technique to assess Skin Turgor?

Answer 8

Pinching below the clavicles & below the wrist bilaterally

Question 9

What is the best assessment for jaundice in dark skinned individuals?

Answer 9

Inspection of the lips, oral mucosa, sclera, conjunctiva, and soles of palms/ feet.

Question 10

Why wash hands before and after every physical client intervention?

Answer 10

To protect examiner and client against the spread of infection.

Question 11

Name the three skin layers and the second layers components

Answer 11

The top layer is the epidermis, and the second layer is the dermis. the dermis contains nerves, blood vessels, hair follicles. The third layer is the subcutaneous layer which is followed by muscle and bones.

Question 12

What is a doppler?

Answer 12

An instrument used to assess pulses when pulses cannot be palpated.

Question 13

What is a wood lamp?

Answer 13

An instrument used to assess for fungal infection of the skin

Question 14

What is a skinfold caliper?

Answer 14

An instrument used to measure thickness subcutaneous tissue.

Question 15

What is a stadiometer?

Answer 15

An instrument used to measure height

Question 16

What is a goniometer?

Answer 16

An instrument used to measure joint extension and flexion

Question 17

Describe a stage 1 decubitus ulcer

Answer 17

First layer of skin intact, erythematous lesion & non-blanchable

Question 18

Describe a Stage II Decubitus Ulcer

Answer 18

A lesion involving 2 layers of tissue, bleeding is observed with partial thickness loss

Question 19

Describe a Stage III Decubitus Ulcer

Answer 19

Lesion involving 3 layers of tissues- epidermis, dermis, and subcutaneous tissue. Full-thickness loss, slough can be present.

Question 20

Describe a Stage IV Decubitus Ulcer

Answer 20

A lesion involving 4 layers of tissue- epidermis, dermis, and subcutaneous tissue and muscle and bones. Full thickness loss, eschar is present or dead tissue

Question 21

When a client suddenly refuses your assessment or exam, what should you do as a Nurse?

Answer 21

Document what was done and what was refused by the client.

Question 22

How is “grading of skin edema” performed?

Answer 22

Press around bony prominences of the body with your third finger pads of both hands. Grade zero- no edema. 1+=2 MM, 2+= 4 MM, 3+= 6 MM, 4+= 8 MM

Question 23

Where are the popliteal pulses located?

Answer 23

located behind the knees medially

Question 24

Where is the radial pulse located?

Answer 24

Located laterally when hands are in supine position at the wrists in line with the thumbs.

Question 25

Where are the ulnar pulses located?

Answer 25

Located medially when the hands are supine position at the wrist in line with the little fingers

Question 26

Where are the brachial pulses located?

Answer 26

The brachial pulses are located at the antecubital area of the arms

Question 27

Where are the femoral pulses located?

Answer 27

The femoral pulses are located at the inguinal areas

Question 28

Describe an annular lesion

Answer 28

A lesion with one circle configuration (Ex. Ringworm or tinea corporis)

Question 29

Describe a target lesion

Answer 29

A lesion with concentric circles of colors inside a lesion with a dot at the center. A.K.A. bull's eye lesion because of the dot at the center of the lesion. (Ex. erythema)

Question 30

Describe a group lesion

Answer 30

Lesions that appear in clusters or are together (Ex. a purpuric lesion)

Question 31

Describe a confluent lesion

Answer 31

Lesions that run together (Ex. Urticaria)

Question 32

Describe discreet lesions

Answer 32

Lesions that are separate (Ex. Molluscum-AKA wart)

Question 33

Describe a wheel lesion

Answer 33

A lesion that is reddened with irregular borders caused by insect bite or hive

Question 34

What is "Port Wine Stain"

Answer 34

A vascular lesion on the face that is flat, deep purple red and irregularly shaped and deepens when person cries or when when the person is highly emotional or exposed to high environmental temperature. Typically, does not fade.

Question 35

Describe Spider Angioma

Answer 35

A vascular lesion, flat, bright red dot with tiny radiating blood vessels ranging from pinpoint to 2 cm

Question 36

Describe venous lake

Answer 36

A vascular lesion on the face, neck, ears, or lips usually common in 50 year old or older, soft, compressible, slightly elevated and ranges from dark blue to purple. May be due to sun exposure.

Question 37

Describe lichenification

Answer 37

Lesions that are rough, thickened, hardened epidermis due to constant scratching and/ or rubbing

Question 38

Describe atrophy

Answer 38

A lesion that is translucent, dry, paper like, sometimes wrinkled due to loss of collagen and elastin

Question 39

Describe a keloid

Answer 39

A lesion that is elevated, irregular darkened area of excess scar tissue

Question 40

Describe ABCDE Criteria

Answer 40

Criteria used to rule out a malignant lesion. A- Asymmetry, B- Border Irregular, C- Varied Colors, D- Diameter (more than 6 mm), and E- Evolving Change

Question 41

Describe Malignant Melanoma

Answer 41

The most serious type of skin cancer because is spread rapidly to the lymph and blood vessels, varied colors, irregular border, and greater than 6 mm

Question 42

What are the predisposition or risk factors of skin cancer?

Answer 42

Overexposure to the UV light and genetic predisposition

Question 43

List the order of occurrence of Herpes Zoster S/S

Answer 43

1) Paresthesia (burning or tingling sensation) 2) Redness and swelling 3) Vesicles/ Blisters 4)Weeping Blisters/ Vesicles 5) Crusted lesions 6) Post-herpetic neuralgia (pain and burning sensation long after blisters disappear. *Cause of Shingles or Herpes Zoster-Chickenpox Virus

Question 44

What are expected findings on a client with Herpes Zoster

Answer 44

Painful lesion that follow along the nerve pathway

Question 45

When assessing a client for physical abuse...?

Answer 45

The first action of the nurse is to report to the supervisor then document.

Question 46

Newborn- Describe Mongolian Spots

Answer 46

harmless purplish-blue spots on the sacral area that are usually common in dark skinned infants. Disappears by age 3.

Question 47

Newborn-what is vernix caseosa?

Answer 47

Harmless white cheese like mixture of sebum and epidermal cells on the skin of the newborn baby. Disappears after several bathing's.

Question 48

Newborn-What is lanugo?

Answer 48

Fine downy hair in a newborn prominent on the upper chest, shoulders, and back.

Question 49

Newborn- What is milia?

Answer 49

Pimple like whiteheads on the nose or cheeks of the newborn which will disappear after 2-3 weeks

Question 50

Newborn- What is vitiligo

Answer 50

Harmless white patchy, depigmented area over the face, neck, hands, and skinfolds of newborn baby. Does not disappear.

Question 51

When an infant's skin appears white, pale blond hair and pink iris, what condition does the baby have?

Answer 51

Absence of Color

Question 52

What are the 2 types of hair?

Answer 52

Vellus hair & Terminal Hair

Question 53

Describe Vellus Hair

Answer 53

fine, pale short hair located all over the body, except lips, nipples, palms, and soles of feet (peach fuzz)

Question 54

Describe terminal Hair

Answer 54

Longer coarser hair located on the eyebrows. scalp, axilla, legs, and for males (face and chest)

Question 55

What are the three Stages of Hair Growth Cycles?

Answer 55

Anagen Phase- growth phase, 2-6 Years Catagen Phase-transitional Phase- 2 Weeks Telogen Phase-Shedding-1-4 months

Question 56

Describe alopecia areata

Answer 56

Sudden loss of hair in a round balding patch on the scalp, can be an autoimmune disease & aggravated by stress

Question 57

How should clubbing of the nails be assessed?

Answer 57

Have the client bring the dorsal aspect of the corresponding fingers together to created a mirror image- normal findings- diamond shaped space between fingers with 160-degree angle of the nail beds.

Question 58

What is Koilonychia

Answer 58

Soft nails that appear spoon shaped due to malnutrition

Question 59

What is Oncholysis

Answer 59

A fungal nail infection, nail thicken, appears white, yellow opaque and lifts off from the nail bed

Question 60

What are beau lines?

Answer 60

Linear depression at the base of the nail and moves distally as nail growth occurs due to trauma or illness

Question 61

Describe Paronychia

Answer 61

Infection of skin adjacent to the nail cause by bacteria or fungi

Question 62

What is a therapeutic response when a client refuses a male nurse to take care of her?

Answer 62

I'll arrange for a female nurse to care for you.

Question 63

What is jaundice?

Answer 63

Skin findings of a client with cirrhosis of the liver

Question 64

What is an indication of physical abuse, and what should a nurse do?

Answer 64

Bruises in various stages of healing on a client is a possible indication of physical abuse. The most appropriate action of the nurse is to report the findings to the supervisor.

Question 65

What is the first action of the nurse in the nursing process

Answer 65

Collection of data, subjective and objective. Subjective is data stated by the client. Objective is data you can see, feel, smell, and hear during your assessment.

Question 66

Describe Pediculosis Capitis

Answer 66

White particles tightly attached to the hair shaft

Question 67

What is Tinea Pedis

Answer 67

Athlete's Foot

Question 68

What id the sequence of the skin, hair, and nails assssments?

Answer 68

1) Inspection 2) Palpation