Module 3 Integumentary

Question 1

What are the 6 vital signs

Answer 1

Temperature, height, weight, respirations, pulse, BP

Question 2

What guideline does a patient have to have to be able to delegate a vital sig to somebody else?

Answer 2

The patient has to be stable

Question 3

What is temperature regulated by?

Answer 3

The hypothalamus in the brain

Question 4

What is the average temp?

Answer 4

98.6

Question 5

What is the normal range of a temperature?

Answer 5

96.4- 100.4

Question 6

If a patient has drank water recently or smoked how long should you wait to take it

Answer 6

15min or more

Question 7

What is the most invasive technique of taking a temperature

Answer 7

Rectal

Question 8

What is the least invasive way of taking a core temp?

Answer 8

Tympanic

Question 9

Exercise, gender, circadian rhythm, age, and environment are examples of

Answer 9

Normal variations of temp alterations

Question 10

Fever, hypothermia (low), hyperthermia (high), heatstroke, heat exhaustion are examples of

Answer 10

Abnormal temp alterations

Question 11

What is pyrexia?

Answer 11

Fever

Question 12

Your patient has a temp of 101.4 should you treat with antipyretics?

Answer 12

No, you only treat a patient with antipyretics if their temp is 102.2 or higher unless ordered by physician

Question 13

What to antipyretics do?

Answer 13

Reduce fever by lowering the body’s set point temp in hypothalamus ex. Tylenol, ibprophen, aspirin

Question 14

What are some fx’s of the skin?

Answer 14

Protection, temp regulation, identification, communication, wound repair, absorption, excretion, produce vitamin d

Question 15

What question could you ask a patient to give subjective data bailout their skin?

Answer 15

Have you noticed any changes with your skin?

Question 16

What health history topics should you ask about pertaining to a patients skin?

Answer 16

If they have a chronic disease, changes in color, rashes, excessive moisture or dryness, swelling (lymphedema), sun protection , medication, smoking

Question 17

What is skin integrity?

Answer 17

How intact or strong the skin is

Question 18

During assessment of the skin what should you analyze the color of the skin based off of?

Answer 18

General pigmentation, localized bruising, any widespread color change

Question 19

What are the 4 types of widespread color changes?

Answer 19

Pallor- when skin has lack of color, can look pale, grey, or more yellow-vasoconstriction
Cyanosis- cause by lack of oxygen in the blood- blue or purple
Jaundice- yellowing of skin caused by increase in bilirubin from liver disease
Erythema- redness of skin caused by increase in temp or allergic rx- vasodilation

Question 20

What is the difference between cyanosis and pallor

Answer 20

Cyanosis is caused by lack of oxygenated blood throughout the body
Pallor is caused by lack of oxygenated blood coming to to them surface of the skin

Question 21

What side of hands should your palpate with

Answer 21

Dorsa (back of hand)

Question 22

Hypothermia vs hyperthermia

Answer 22

Cold vs hot

Question 23

Your patient has a high temp and while assessing their skin you very most all throughout this is an example of

Answer 23

Diaphoresis

Question 24

When testing the skin turgor, where should you tent the skin?

Answer 24

Collarbone or sternum, NOT back of hand

Question 25

When you test skin turgor how long should it take for the skin to fully release?

Answer 25

3’s, 4s for elderly

Question 26

what does turgor test?

Answer 26

Elasticity and hydration of skin

Question 27

Edema

Answer 27

Swelling of skin

Question 28

Macule

Answer 28

Flat, circumscribed, color change- freckles

Question 29

Papule

Answer 29

Solid,elevated, circumscribed- raised mole

Question 30

Nodule

Answer 30

Solid, elevated, extends into dermis- cyst

Question 31

Tumor

Answer 31

Firm soft deep into dermis- > 2-3 cm

Question 32

Wheal

Answer 32

Superficial raised, irregular erythematous, Irregular- allergic rxn, hives

Question 33

Vesicle

Answer 33

Elevated filled with clear serum- herpes, chicken pox

Question 34

Pustule

Answer 34

Pus filled cavity, circumscribed, elevated- pimple

Question 35

Ulcer

Answer 35

Deep loss of skin surface that extends to dermis, frequently bleeds

Question 36

Atrophy

Answer 36

Thinning of skin with loss, skin appears shiny or translucent

Question 37

What method can you use to determine abnormal malignant skin lesion

Answer 37

A- asymetrical B-boarders C-color D-diameter-6mm E- elevated

Question 38

You are doing a physical assessment of your patients nails and notice their nail bed profile is distorted with an angle of more than 108 degrees. What is the called what causes it?

Answer 38

Clubbed fingers, cause by hypoxia

Question 39

When testing capillary refill, how long should it take for patients to nail bed to turn red again?

Answer 39

3s, 4 for elderly

Question 40

What factors contribute to a patients hygiene practices?

Answer 40

Culture and age

Question 41

Hygiene is routine true or false

Answer 41

False- hygiene routines are specific rot the patient depending on their culture age, beliefs, and physical/ mental status

Question 42

You notice when your patient tried to sit up in bed it is a struggle and cannot complete task without assistance , it is hard for them to breathe and they get very light headed. This is an example of

Answer 42

Activity intolerance

Question 43

A nurse is caring for a patient who has been diagnosed with activity intolerance due to heart failure. Which of the following is the most important intervention to promote activity tolerance in this patient? A) encourage the patient to rest in bed all day B) assess the patients vital signs before during and after any activity C) provide a high calorie diet to promote energy levels D) encourage patient to perform deep breathing exercises everyday

Answer 43

B- monitoring patients vitals signs helps determine the patients tolerance to activity and ensures that any potential adverse reaction are addressed promptly

Question 44

A nurse is caring for a patient with a bathing self care deficit due to recent hip surgery. Which interventions would be most appropriate to assist this patient? A) encourage the patient to take a full shower independently B) offer the patient a bed bath while maintain privacy and comfort C) Instruct the patient to avoid bathing until they are completly healed D) perform the entire bathing task for the patient to prevent discomfort

Answer 44

B- allows for hygiene while considering their limitations and promoting independence