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ET ABSN > 307 Exam 1 (Modules 1-3) > Flashcards

307 Exam 1 (Modules 1-3) Flashcards

1
Q

What are the techniques used for a skin assessment?

A

Inspection and Palpation

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2
Q

What do we Inspect the skin for?

A

Color, Texture, Integrity

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3
Q

What do we palpate the skin for?

A

Moisture/Temp, texture, mobility and turgor.

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4
Q

What 3 sources do humans obtain Vitamin D?

A

Sunlight, Food and Dietary supplements

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5
Q

What 5 functions do the skin have?

A

Protect inner body parts and organs
Body Temp regulation
Sensor perception of temp, touch and pain
Excrete wastes and toxic substances
Produce Vitamin D

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6
Q

What are three examples of hyperpigmentation?

A

Birth Marks
Sun Damage
Pregnancy changes

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7
Q

3 examples of hypopigmentation?

A

Scars, stretch marks and vitiligo

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8
Q

What is Vitiligo?

A

The lack or absence of the brown melanin pigment

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9
Q

Cyanosis

A

Blue or Purplish discoloration of the skin (Easiest to see at fingers, lips, toes)

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10
Q

Ecchymosis

A

Bruising (Bleeding under the skin)
Larger than Petechiae.
Greater than 3mm

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11
Q

Erythema

A

Redness of the skin caused by the dilation of the superficial capillaries.

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12
Q

Jaundice

A

Yellow discoloration of the skin and mucous membranes sclerae due to abnormal amounts of bilirubin in the blood.

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13
Q

Pallor

A

A paleness or decrease of absence of skin coloration.

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14
Q

Petechiae

A

Small round purplish red spots.
Caused by hemorrhage into the skin.
1-3mm

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15
Q

Atrophic Scars

A

Have a depression in them from lost of epidermis

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16
Q

Striae and Stretch marks are what type of scars?

A

Atrophic Scars

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17
Q

Keloid Scars

A

Extends over the border of original wound and is smooth and rubbery

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18
Q

How long does is take keloid scars to appear after the original injury?

A

Anywhere from Months-Years

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19
Q

Extremely smooth and velvety skin could indicate what?

A

Thyroid disease

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20
Q

What is Diaphoresis?

A

Excessive Precipitation

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21
Q

How should you describe any skin lesions?

A

Color
Height
Shape
Location
Presence of drainage

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22
Q

Purpura

A

Collection of petechiae and ecchymosis covering an area.

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23
Q

What are Vascular lesions?

A

trauma, infection, or disease that allow leakage of capillaries into the dermis

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24
Q

Petechiae/ Purpura and Ecchymosis are what type of lesions?

A

Vascular

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25
Q

What lesions have a specific triggering agent which cause a change in previously intact skin?

A

Primary

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26
Q

Freckles, Mole, Measles, Scarlet Fever

A

Macule (FLAT)
Less than 1CM area of pigment change.

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27
Q

Birthmark, Vitiligo and hormone changes?

A

Patch (FLAT)
Larger than 1CM area of pigment change

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28
Q

Wart, Elevated Mole, Skin Tag

A

Papule (RAISED)
Less than 1CM area

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29
Q

Psoriasis, Eczema

A

Plaque (RAISED)
Larger than 1CM and in a disc shape.

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30
Q

Insect bites, Allergic Reaction and Hives (TB test is also one)

A

Wheal (RAISED, SOLID)
Irregular area of edema on skin

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31
Q

Melanoma, hemangioma

A

Nodule (RAISED, SOLID)
Less than 2CM firm area rising from deeper in the dermis

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32
Q

Lipoma and Neoplasm

A

Tumor (RAISED, SOLID)
Larger than 2CM firm area rising from deeper in the dermis

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33
Q

Varicella chicken pox, shingles (Usually follows a nerve pathway) acute eczema

A

Vesicle (RAISED AND FLUID FILLED)
less than 1CM and filled with serous fluid

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34
Q

Blister, Medication reaction

A

Bulla (RAISED AND FLUID FILLED)
greater than 1CM and filled with serous fluid.

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35
Q

Acne, Herpes Simplex

A

Pustule (RAISED AND FLUID FILLED)
less than 1CM and filled with purulent fluid.

36
Q

Cyst acne or Sebaceous Cyst

A

Cyst (RAISED AND FLUID FILLED)
arising from dermis filled with liquid or semisolid fluid.

37
Q

These lesions evolve over time with changing characteristics

A

Secondary lesions

38
Q

Chronic skin inflammation and Psoriasis

A

Lichenification, caused by long term and intense rubbing or scratching.

39
Q

Scab and Eczema

A

CRUST, caused by intense rubbing or scratching.

40
Q

Psoriasis or Eczema

A

SCALE, excessive shedding of keratin cells from the epidermis.

41
Q

Cracks in the corner of the mouth or extremely dry hands and feet

A

FISSURE, straight line crack with abrupt edges going into the dermis.

42
Q

Varicella, herpes simplex

A

EROSION, shallow depression appears moist but without bleeding.

43
Q

Pressure Injury or poor blood flow to extremities

A

ULCERATIONS, may bleed.

44
Q

Abrasions or scratching

A

Excoriation loss of epidermis in linear crusted areas.

45
Q

True or False
Patients with a lighter skin tone and exposure to UV rays have higher chance of developing skin cancer?

A

True

46
Q

What is the ABCDE rule for assessing malignant skin lesions?

A

A asymmetry
B border
C color
D diameter
E evolving

47
Q

-Red Area does not blanch with pressure
-Texture different than surrounding areas
- Temp warmer or cooler than surrounding areas

A

Stage 1 pressure Ulcer

48
Q

-Partial loss of Dermis
- Shiny or dry ulcer with pink wound bed
-May present as ruptured blister or intact

A

Stage 2 Pressure Ulcer

49
Q

-Full Tissue loss with damage or necrosis to the subcutaneous tissue
-Subcutaneous fat may be visible
- Dead tissue may be present in the wound bed.

A

Stage 3 Pressure Ulcer

50
Q

-Full thickness and skin loss resulting in showing bones, tendons or muscles.
-Dead tissue may be present in the wound bed.

A

Stage 4 Pressure Ulcer

51
Q

Hyperthermia or hypothermia?
-Shaking
-Blurred Speech
-Sleepiness
Stiff Muscles
-Confusion

A

Hypothermia

52
Q

Hyperthermia or hypothermia?
-Swelling in ankles or feet
-Nausea/Weakness
-Muscle cramps
-Rapid pulse

A

Hyperthermia

53
Q

Xerosis

A

Dry Skin

54
Q

Nevus

A

Mole

55
Q

Hives, skin rash with red raised and itchy bumps

A

Urticaria

56
Q

Intense itching causing the desire to scratch

A

Pruritus

57
Q

What are the 5 stages of the nursing process?

A

Assessment
Analysis
Planning
Implementation
Evaluation

58
Q

Avoiding harm to others is an example of what ethical principal?

A

Nonmaleficence

59
Q

Protecting the privacy of others is what ethical principal?

A

Confidentiality

60
Q

Helping others in a positive manner is an example of what ethical principal?

A

Beneficence

61
Q

Being open and fair describes what ethical principal?

A

Justice

62
Q

Having control over your body and what happens to it is an example of what ethical principal?

A

Autonomy

63
Q

True or false Therapeutic communication can be both verbal and non verbal?

A

True

64
Q

ISBARR

A

Identify
Situation
Background
Assessment
Recommendation
Recite

65
Q

What does HIPPA stand for?

A

Health Insurance Portability and accountability act

66
Q

Keeping a promise to a client is known as what ethical principal of nursing?

A

Fidelity

67
Q

RR > 10-12/min

A

Bradypnea

68
Q

HR >50/min

A

Bradycardia

69
Q

HR< 100/min

A

Tachycardia

70
Q

Shallow rapid breathing <20/min

A

Tachypnea

71
Q

Give verbal instruction for how to take a orthostatic BP in 5 steps.

A

1 Place pt in supine position and allow to rest.
2 Take BP
3 Keep cuff in place and assist to seated
4 Take BP while stated
5 Assist to stand and get BP

72
Q

True or False
120/80 is normal findings for an adult blood pressure

A

True

73
Q

-Pt reports fever, malaise, chills, pain
Multiple or single lesions (pustules, papule, nodular)
-Lesions can be erythematous, edematous, painful, and warm to touch.

A

Cellulitis

74
Q

give examples of nursing actions when a patient has sensory disability

A

-Keep call light accessible
orient clients to the room
-keep furniture clear from path to the bathroom
-Keep client’s personal items within reach
-Bed lowest position
-poles bags and tubes easy to move around.

75
Q

Examples of nursing actions for hearing loss

A

-Sit and face clients
-Speak slowly and clearly
-Write down what client’s don’t understand

76
Q

Examples of nursing actions for patients with vision loss

A

-Identify yourself
-Stay within visual field if only partial loss
-Make digital audio or radio available
-Describe an arrangement of food on a tray before leaving.

77
Q

Nursing actions for patients with aphasia

A

-Do not shout
-Check for comprehension
-Make sure only one person speaks at a time.

78
Q

Nursing actions for patients who are disoriented

A

Maintain Eye contact at eye level
Ask only one question at a time
Give directions one step at a time.

79
Q

For the GENERAL SURVEY what should we notice about the patient

A

Appearance
Behavior
Body Structure
Mobility

80
Q

What objective information do we obtain from a patient during the GENERAL SURVEY

A

Height
Weight
BMI
Vital Signs
Pain Scale Assessment

81
Q

When assessing behavior what 3 things should you take notice of?

A

Speech, Mood and Affect.

82
Q

During the general survey what unexpected findings should the nurse look for in a patients awareness?

A

Confusion (Awake)
Lethargy (Not fully awake)
Stupor (Unconscious but responds to stimuli physical or verbal )
Obtundation (Is asleep, only arouses with loud audio or physical interaction)
Comatose (Unconscious and no stimuli reaction)

83
Q

Obtundation

A

A reduction in awareness in which environmental stimuli fail to illicit a reaction from patient.

84
Q

What is Echolalia

A

Meaningless repetition of words.

85
Q

What is Dysarthria?

A

Difficult or unclear articulation of speech.

86
Q

What is Crepitus

A

Cracking sound when bone rubs together.

87
Q
A

ET ABSN (4 decks)

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