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Health Assessment > Skin, Nails, Hair, and Wounds, Ch. 13 > Flashcards

Skin, Nails, Hair, and Wounds, Ch. 13 Flashcards

1
Q

Annular/Circular

A

It begins in the center and spreads to the periphery

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2
Q

Confluent

A

Lesions run Together

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3
Q

Discrete

A

Distinct and Separate

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4
Q

Grouped

A

Cluster of Lesions

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5
Q

Gyrate

A

Twisted, Coiled Snakelike

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6
Q

Target/Iris

A

Iris of Eye, Concentric rings

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7
Q

Linear

A

Scratch, Streak Line or Stripe

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8
Q

Polycystic

A

Annular Lesions grow together

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9
Q

Zosteriform

A

Linear arrangement following a unilateral nerve route

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10
Q

Ecchymosis

A

Bruising, a large patch of capillary burst into tissue

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11
Q

Normal Nail

A

160 degress

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12
Q

Clubbing

A

180 degrees+, found in COPD patients

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13
Q

Erythmea

A

Intense redness in the skin

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14
Q

Jaundice

A

Yellowish skin color, rising amounts of bilirubin

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15
Q

Cyanosis

A

Bluish color from decreased perfusion, high levels of deoxygenated blood

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16
Q

Pallor

A

Skin takes color of connective tissue; pale

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17
Q

Factors of Pressure Injury Development

A

Age
Moisture
External Pressure
Immobility
Nutrition
Hydration
Friction and Shear
Mental Status

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18
Q

Braden Scale 6 Categories

A

Friction and Shear
Mobility
Activity
Moisture
Nutrition
Sensory Perception

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19
Q

Stage 1 Pressure Injury

A

Intact Skin with nonblanchable redness

19
Q

Stage 2 Pressure Injury

A

Partial Thickness, Loss of dermis, as abrasion or blister

19
Q

Stage 3 Pressure Injury

A

Full Thickness, Subcutaneous Tissue Visible, presents as deeper crater

20
Q

Stage 4 pressure Injury

A

Full thickness Loss, Tissue Necrosis, Bone and Tendons are visible

21
Q

RYB Wound Classification

A

Classification by Color, Practical method of evaluating wounds and determining treatment options

22
Q

What are the components of the ABCDE Assessment?

A

A- Asymmetry
B- Border
C- Color
D- Diameter
E- Elevation and Enlargement

23
Q

Red Wound

A

R=Red=Protect.
Health granulation tissue, Gentle Cleansing, use of Moist Dressing, Changing when Necessary

24
Q

Yellow wound

A

Y=yellow=Cleanse
Irrigating, use wet to moist dressing, topical antimicrobial
medication, nonadherent dressing

25
Q

Black Wound

A

B=Black=Debride
Presence of Eschar, requires debridement, Cared for advanced practice nurses.

after debridement treated as yellow wound.

26
Q

When assessing inflammation in a dark-skinned person, the nurse may need to:
A. Assess the skin for cyanosis and swelling
B. Assess the oral mucosa for generalized erythema
C. Palpate the skin for edema and increased warmth
D. Palpate the skin for tenderness and local areas of ecchymosis

A

C

27
Q

The nurse just noticed that a patient has a lesion that is confluent in nature. On examination what would the nurse expect to find?

A. Lesions that run together
B. Annular lesions that have grown together
C. Lesions arranged in a line along a nerve route
D. Lesions that are grouped or clustered together

A

A

28
Q

The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions?

A. Cases of severe obesity
B. During childhood growth spurts
C. In an individual who is severely dehydrated
D. Has a connective tissue disorder

A

C

29
Q

A 52-year-old woman has a papule on her nose that has a rounded, pearly border and a central red ulcer. She said she has noticed it for several months and it has slowly grown larger. The nurse suspects which condition?

A. Acne
B. Basal cell carcinoma
C. Malignant melanoma
D. Squamous cell carcinoma

A

B

30
Q

Nodule

A

Solid, Elevated, Hard or soft larger than 1 cm, tumor like

31
Q

Petechiae

A

Tiny punctuate hemorrhages, 1-3mm, round, and discrete, dark red, purple, or brown in color

32
Q

Keloid

A

Excess scar tissue beyond original cut

33
Q

Vesicle

A

Elevated cavity containing free fluid, up to 1 cm. Clear Serum flows if wall is ruptured.

34
Q

Hematoma

A

Bruise that causes blood to collect and pool under the skin

35
Q

Wheal

A

Usually comes from an Allergic Reaction

36
Q

Cyst

A

Noncancerous growth filled with liquid or semisolid substance

37
Q

pustule

A

Small blister or pimple on skin containing pus

38
Q

Crust

A

Rough elevated area formed from dry fluid

39
Q

Scale

A

Symptom in patients with psoriasis, eczema, fungal infections or contact dermitis.

40
Q

Fissure

A

linear, breaks in the skin surface, as a result of excessive dryness (xerosis)

41
Q

Excoriation

A

Lesions on the surface of the skin following a trauma (rash, skin infection, injury)

42
Q

Basal Cell Carcinoma

A

appears as waxy lump or brown scaly patch on sun-exposed areas, Face and neck, cancer

43
Q

Squamous Cell Carcinoma

A

flat, reddish or brownish patches on the skin, often with rough or scaly crusted surface

44
Q

Malignant Melanoma

A

UV light, Pigment producing cells become cancerous, a change in size, shape, color, or feel of existing mole

45
Q

Kaposi Sarcoma

A

Opportunistic, Causes lesions in soft tissue, looks like a bruise, doesn’t loose color when pressed.

Health Assessment (7 decks)

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