Study guide for test 3 nur 101

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Study guide for test 3 nur 101
2013-09-08 21:52:01
nursing 101 study guide test

skin, hair, nails, eyes, ears Assessment Lab
Show Answers:

  1. Tips for organizing the physical assessment and creating proper environment
    • Privacy, Quiet, Temperature of Room, Light
    • Hand Hygiene, short nails warm hands
  2. when doing physical assessment on pt what are some general rules
    • work head to toe
    • compare one side to the other
    • use specific terminology
  3. What are normal skin findings for older adults?
    • Loss of elasticity, and subcutaneous fat
    • Sweat Glands are less active
    • Telangectasias
    • skin is thinner so it tears easily
  4. what would expect to see when examining the hair of older adults?
    • they can have Hair loss
    • and sometimes their hair is coarse
  5. Pallor
    • pale
    • the result of inadequate circulation
  6. erythema
  7. cyanosis
    blue-bluish tinge
  8. Jaundice
  9. Edema
  10. Macule
  11. Papule
  12. Vesicle
  13. Urticaria
  14. Atrophy
    thing, shrinking
  15. Erosion
    • scratch mark
    • will heal without a scar
  16. Lichenification
    • rough
    • thick
  17. Scales
  18. Crust
  19. Ulcer
    pressure sore
  20. Fissure
  21. Excoriation
    Burn (chemical Burn)
  22. Ecchymosis
  23. when describing a skin lesion you describe ....
    • Type or Structure
    • Size, shape, texture
    • color
    • distribution
    • configuration
  24. what are the type or structures of skin lesions?
    • primary -appear initially to reaction in the internal or external environment
    • secondary - do not appear initially but result from primary lesion.
  25. how do you describe size, shape and texture of lesion
    • millimeters
    • circumcised, irregular, round, oval
    • flat, elevated, or depressed
    • fluid filled, has flakes,
    • solid, soft, hard, rough or thickened
  26. skin lesion describe color
    • there may be no color, one color or many colors
    • as with ecchymosis starts dark red or blue then fades to yellow
  27. when the color fades of a lesion are limited to the edges they are described as .....
  28. what are the characteristics of a circumcised lesion?
    the color change that occurs they are limited to the edges of the lesion
  29. when the color change process of a lesion spreads all over the lesion it is called...
  30. describe diffuse lesion
    when the color changing process spreads over a large area of the lesion.
  31. when describing a lesion what is meant by distribution?
    location of the lesion on the body and symmetry or asymmetry of the findings in comparable body areas.
  32. describing lesions what is configuration
    • refers to the arrangement of the lesions in relationship with each other
    • Annular
    • grouped
    • linear
  33. annular lesion
    lesions arranged in a circle
  34. clustered lesions
    grouped together
  35. alopecia
    hair loss
  36. describe infant nails
    • thin
    • grow quickly
  37. why do children bite their nails
  38. elderly nails
    • thick
    • grow slowly
    • fungus is common
  39. what is capillary refill
    • the amount of time it take for color to come back in nail after pressing on it
    • should go back in 3 seconds
  40. what is normal for infants skin
    • milia-white heads
    • vernix caseosa -white greasy on baby when born
    • lanugo in premature-really fine hair
    • sacral hyperpigmentation in dark skinned babies
  41. what is normal to see in the skin of children
    • bruising/abrasion
    • acne
  42. when assessing the nail what do you look at
    • color
    • condition
    • abnormalities
    • texture
    • capillary refill
  43. describe healthy oropharynx.
    • hard and soft palate pink and intact
    • tonsils pink
    • no lesions or exudates
    • symmetrical rise of uvula
    • positive swallow reflex
  44. how to assess for the gag reflex
    touch the back of the soft palate with the tongue blade.
  45. why is the absence of gag reflex a risk for the client?
    it put the client at risk for aspiration
  46. why would a nurse assess a client for gag reflex?
    if pt is unresponsive and they need to provide oral care
  47. what creates fontanelles in an infant?
  48. how to assess for a malignant lesion
    • A-asymmetry
    • B-border irregularity
    • C-color variation
    • D-diameter >0.5cm
    • E-elevation or enlargement