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

Question 1

Annular/Circular

Answer 1

It begins in the center and spreads to the periphery

Question 2

Confluent

Answer 2

Lesions run Together

Question 3

Discrete

Answer 3

Distinct and Separate

Question 4

Grouped

Answer 4

Cluster of Lesions

Question 5

Gyrate

Answer 5

Twisted, Coiled Snakelike

Question 6

Target/Iris

Answer 6

Iris of Eye, Concentric rings

Question 7

Linear

Answer 7

Scratch, Streak Line or Stripe

Question 8

Polycystic

Answer 8

Annular Lesions grow together

Question 9

Zosteriform

Answer 9

Linear arrangement following a unilateral nerve route

Question 10

Ecchymosis

Answer 10

Bruising, a large patch of capillary burst into tissue

Question 11

Normal Nail

Answer 11

160 degress

Question 12

Clubbing

Answer 12

180 degrees+, found in COPD patients

Question 13

Erythmea

Answer 13

Intense redness in the skin

Question 14

Jaundice

Answer 14

Yellowish skin color, rising amounts of bilirubin

Question 15

Cyanosis

Answer 15

Bluish color from decreased perfusion, high levels of deoxygenated blood

Question 16

Pallor

Answer 16

Skin takes color of connective tissue; pale

Question 17

Factors of Pressure Injury Development

Answer 17

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

Question 18

Braden Scale 6 Categories

Answer 18

Friction and Shear
Mobility
Activity
Moisture
Nutrition
Sensory Perception

Question 19

Stage 1 Pressure Injury

Answer 19

Intact Skin with nonblanchable redness

Question 19

Stage 2 Pressure Injury

Answer 19

Partial Thickness, Loss of dermis, as abrasion or blister

Question 19

Stage 3 Pressure Injury

Answer 19

Full Thickness, Subcutaneous Tissue Visible, presents as deeper crater

Question 20

Stage 4 pressure Injury

Answer 20

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

Question 21

RYB Wound Classification

Answer 21

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

Question 22

What are the components of the ABCDE Assessment?

Answer 22

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

Question 23

Red Wound

Answer 23

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

Question 24

Yellow wound

Answer 24

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

Question 25

Black Wound

Answer 25

B=Black=Debride Presence of Eschar, requires debridement, Cared for advanced practice nurses. after debridement treated as yellow wound.

Question 26

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

Answer 26

C

Question 27

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

Answer 27

A

Question 28

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

Answer 28

C

Question 29

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

Answer 29

B

Question 30

Nodule

Answer 30

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

Question 31

Petechiae

Answer 31

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

Question 32

Keloid

Answer 32

Excess scar tissue beyond original cut

Question 33

Vesicle

Answer 33

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

Question 34

Hematoma

Answer 34

Bruise that causes blood to collect and pool under the skin

Question 35

Wheal

Answer 35

Usually comes from an Allergic Reaction

Question 36

Cyst

Answer 36

Noncancerous growth filled with liquid or semisolid substance

Question 37

pustule

Answer 37

Small blister or pimple on skin containing pus

Question 38

Crust

Answer 38

Rough elevated area formed from dry fluid

Question 39

Scale

Answer 39

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

Question 40

Fissure

Answer 40

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

Question 41

Excoriation

Answer 41

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

Question 42

Basal Cell Carcinoma

Answer 42

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

Question 43

Squamous Cell Carcinoma

Answer 43

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

Question 44

Malignant Melanoma

Answer 44

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

Question 45

Kaposi Sarcoma

Answer 45

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