Assessment of Skin and palpation (Procedural)

Question 1

In inspecting the skin color, what is the normal finding in white/fair skin?

Answer 1

Light to
dark pink

Question 2

In inspecting the skin color, what is the normal finding in dark skin?

Answer 2

light to dark
brown, olive

Question 3

In inspecting the skin color, what is the abnormal finding in white skin?

Answer 3

Extreme
pallor, flushed, bluish
(cyanosis)

Question 4

In inspecting the skin color, what is the abnormal finding in dark skin?

Answer 4

Loss of red
tones in pallor; ashen gray
in cyanosis. Bluish colored palms, soles, lips, nails, and earlobes are seen with cyanosis.

Question 5

seen in vasoconstriction,
myocardial infraction, or
pulmonary insufficiency.

Answer 5

Cyanosis

Question 6

seen in arterial
insufficiency and anemia.

Answer 6

Pallor

Question 7

In inspecting uniformity of skin color, what is the normal variation in color patches In white/fair skin?

Answer 7

Sun tanned areas, white
patches (vitiligo)

Question 8

In inspecting uniformity of skin color, what is the normal variation in color patches In dark skin?

Answer 8

lighter colored palms, soles,
nail beds, and lips;
black/blue area are
over lower lumbar
area (Mongolian
spots); freckle-like
pigmentation of nail
beds and sclerae

Question 9

In inspecting uniformity of skin color, what is the abnormal variation in color patches In white/fair skin?

Answer 9

Generalized pale yellow to
pumpkin color (jaundice)

Question 10

In inspecting uniformity of skin color, what is the abnormal variation in color patches In dark skin?

Answer 10

Yellow color may appear in sclerae, oral mucous membranes, hand
and soft palates, palms,
and soles.

Question 11

Jaundice is
often seen in…

Answer 11

liver or gallbladder
disease, hemolysis, or anemia

Question 12

In inspecting uniformity of skin color, what are the abnormal variation in color patches the overall skin?

Answer 12

increased pigmented areas;
decreased pigmented areas,
reddened, warmed areas
(erythema); black and blue
marks (ecchymosis); tiny red
spots (petechiae).

Question 13

How do you assess edema?

Answer 13

Press firmly for 5-
10 seconds over tibia and
ankle

Question 13

How do you determine the presence of edema?

Answer 13

color, temperature, shape, and the degree to which the skin remains indented or pitted when pressed by a finger

Question 14

In assessing if Edema is present, what is the normal condition?

Answer 14

No swelling, pitting, or
edema

Question 15

In assessing if Edema is present, what is the abnormal condition?

Answer 15

Swollen, shallow to deep
pitting, ascites (condition in which fluid collects in spaces within your abdomen).

Question 16

Scale for Describing Edema

Answer 16

1+ Barely detectable (2mm)
2+ Indentation of 2-4 mm
3+ Indentation of 5-7 mm
4+ Indentation of < 7 mm

Question 17

Generalized edema is seen
in…

Answer 17

congestive heart failure or
kidney disease.

Question 18

Unilateral localized edema
is seen in…

Answer 18

peripheral vascular
problems such as venous
stasis, obstruction, or
lymphedema.

Question 19

In Inspect, palpate, and
describing skin lesions, what should you do if if lesions are open or draining and why you should do it.

Answer 19

Apply Gloves.

To protect nurse from contamination of the discharges present from
the lesion/s.

Question 20

If a skin lesion is
detected…

Answer 20

Inspect and palpate for size, location, mobility,
consistency, and pattern (circular, clustered, or straight-lined).

Question 21

In inspect, palpate, and
describing skin lesions, what is the normal condition?

Answer 21

Silver-pink stretch marks
(striae), moles (nevi),
freckles, birthmarks.

Question 22

In observing and palpating texture, temperature and
skin moisture, what should you consider?

Answer 22

Temperature and
moisture: feel with back of
hand (Compare the two feet and the two hands, using the backs of your fingers).

Question 23

In inspect, palpate, and
describing skin lesions, what is the abnormal condition?

Answer 23

Primary lesions (arises from normal skin being subjected to diseases or irritations)

Secondary lesions (arise from changes in primary lesions)

Vascular lesions (may
be seen with increased venous pressure; aging, liver disease, or pregnancy.

Skin cancer may manifest from either primary or secondary lesions.

Question 24

In observing and palpating texture, temperature and skin moisture, what are the normal conditions?

Answer 24

Texture : Smooth Temperature and moisture: Warm, dry

Question 25

In observing and palpating texture, temperature and skin moisture, what are the abnormal condition?

Answer 25

Rough and thick skin (Dry skin is seen in hypothyroidism) Extremely cool or warm, wet, oily. (Cold skin is seen in shock, hypotension, arterial insufficiency while very warm skin is seen in fever and hyperthyroidism.

Question 26

How do you note skin turgor?

Answer 26

Pinch up skin on sternum or under clavicle

Question 27

In noting skin turgor, what is the normal condition?

Answer 27

Pinched-up skin returns immediately to original position.

Question 28

In noting skin turgor, what is the abnormal condition?

Answer 28

Pinched-up skin takes 30 seconds or longer to return to original position (Turgor is decreased in dehydration)

Question 29

In inspecting amount of body hair, what is the normal amount?

Answer 29

Vary

Question 30

In inspecting amount of body hair, what is the abnormal amount?

Answer 30

Hirsutism (abnormal hairiness in women)