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3306 Final > Week #2: Hair, Skin, Nails, & Eyes/Ears > Flashcards

Week #2: Hair, Skin, Nails, & Eyes/Ears Flashcards

1
Q

The nurse recognizes that the 60-year-old patient may have difficulty reading the fine print because of:
a) the loss of accommodation
b) amblyopia
c) asthenopia
d) the unequal size of the pupils

A

a) the loss of accommodation

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2
Q

A new nurse on the long-term care unit is learning how to assess a client’s risk for skin breakdown. What would be the most likely instrument this nurse would use?
a) Newton scale
b) Norton scale
c) Head-to-toe assessment
d) Braden scale

A

d) Braden scale

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3
Q

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?
a) Dermatoma
b) Angioma
c) Melanoma
d) Nevus

A

c) Melanoma

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4
Q

A client tells a nurse about a raised lesion on the client’s leg. What is the nurse’s first nursing action?
a) Palpate the area
b) Move to the next body system
c) Inspect the area
d) Document the statement

A

c) Inspect the area

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5
Q

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?
a) Tenting indicates dramatic weight loss
b) Tenting indicates malnutrition
c) Tending indicates vitamin B12 deficiency
d) Tenting indicates dehydration

A

d) Tenting indicates dehydration

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6
Q

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
a) Connective layer
b) Dermis
c) Subcutaneous layer
d) Epidermis

A

b) Dermis

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7
Q

Peripheral vision is evaluated by the nurse using the:
a) Confrontation test
b) Cardinal fields of gaze test
c) Cover test
d) Corneal light test

A

a) Confrontation test

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8
Q

What does PERRLA stand for?

A

Pupils Equal Round Reactive Light Accommodation

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9
Q

What does HOH stand for?

A

Hard of Hearing

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10
Q

When using an otoscope to assess the inner ear, the nurse should hold the patient’s ear at the helix, lifting up and back for best visualization.
a) True
b) False

A

a) True

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11
Q

Outermost skin layer; has NO blood supply and is nourished almost exclusively by oxygen from the surface air.
- also contains specialized cells responsible for perception of pain, light touch, vibration, and temperature as well as detection of foreign antigens
a) Dermis
b) Epidermis
c) Subcutaneous layer

A

b) Epidermis

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12
Q

Innermost skin layer; provides insulation, storage of caloric reserves, and cushioning against external forces.
- composed mainly of fat & loose C.T.
a) Dermis
b) Epidermis
c) Subcutaneous layer

A

c) Subcutaneous layer

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13
Q

Second skin layer; contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which provide for protective function
a) Dermis
b) Epidermis
c) Subcutaneous layer

A

a) Dermis

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14
Q

Bluish discoloration

A

Cyanosis

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15
Q

Dark, leathery appearance

A

Brawny

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16
Q

Redness

A

Flushing, erythema

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17
Q

Yellow discoloration of skin & sclerae

A

Jaundice

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18
Q

Paleness

A

Pallor

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19
Q

Dependent redness

A

Rubor

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20
Q

A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status.
a) True
b) False

A

a) True

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21
Q

Skin changes related to aging include melasma, linea nigra, increased sebaceous and cutaneous gland function, and hair loss.
a) True
b) False

A

b) False

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22
Q

The older adult has __________ skin texture and prolonged time for __________ healing, and thermoregulation changes increase the risk for hypo- & hyperthermia.

A

Rougher; Wound

23
Q

Skin _______-examination assists patients to identify problematic lesions.

A

Self

24
Q

The depth of a burn can be superficial, superficial-dermal, dermal, or __________ thickness.

A

Full

25
Q

Tenting of the skin indicates ____________.

A

Dehydration

26
Q

What are the 6 categories of the Braden Scale?

A

1) Sensory perception
2) Moisture
3) Activity
4) Mobility
5) Nutrition
6) Friction/Shear

27
Q

What are the ABCDEs for assessing Melanoma?

A

a) Asymmetry
b) Border
c) Color
d) Diameter
e) Evolution

28
Q

Tests extraocular muscles for symmetrical movements of the eyes in 9 fields

A

Cardinal Fields of Gaze

29
Q

Tests for visual field defects

A

Confrontation Test

30
Q

Assesses near vision

A

Jaeger Test

31
Q

Tests for presence & amount of ocular deviation

A

Cover Test

32
Q

Assesses distance visual acuity

A

Snellen Test

33
Q

Patients older than 40-years often have increased ability to accommodate, moving the object further away to read.
a) True
b) False

A

b) False

34
Q

A patient with 20/20 vision can read at 20ft. what the normal person can read at 20ft.
a) True
b) False

A

a) True

35
Q

Cranial nerves involved with the eyes include II, III, IV, and V.
a) True
b) False

A

b) False

36
Q

Cloudiness in the lens can indicate a ____________.

A

Cataract

37
Q

____________ is documented when the pupils are equal, round, and reactive to light & accommodation.

A

PERRLA

38
Q

____________ is the leading cause of blindness in middle & older adults.

A

Diabetic Retinopathy

39
Q

The Weber test differentiates bilateral hearing loss.
a) True
b) False

A

b) False

40
Q

Nonverbal cues of hearing loss include leaning forward, concentrating on lip reading, or giving incorrect answers to questions asked.
a) True
b) False

A

a) True

41
Q

The inner ear contains the malleus, incus, and stapes that conduct sound waves to the middle ear.
a) True
b) False

A

b) False

42
Q

Environmental factors that increase the risk for otitis media include secondhand smoke, propping bottles for babies to feed, and bottle feeding in the supine position.
a) True
b) False

A

a) True

43
Q

The _________ membrane is the barrier between the external auditory canal and the middle ear.

A

Tympanic

44
Q

The semicircular canals and vestibule provide the body with _____________ and equilibrium.

A

Proprioception

45
Q

Color & consistency of __________ differs according to cultural background.

A

Cerumen

46
Q

____________ hearing loss is caused by either blockage of the external auditory canal by cerumen or fluid in the middle ear.

A

Conductive

47
Q

How should the nurse hold the ear of an adult patient when performing an otoscopic exam?

A

Hold at helix, lift up & back

48
Q

Testing the difference between sound transmission via air or bone conduction

A

Rinne Test

49
Q

S&S of infection:

A
  • rash & fever in a patient raises suspicion of an infectious process
  • multiple lesions
  • increased WBC count
50
Q

helps to differentiate cause of unilateral hearing loss
- sound should be in both ears (abnormal = unilateral ID)

A

Weber test

51
Q

examines the difference between bone conduction and air conduction

A

Rinne Test

52
Q

An ear assessment includes:

A
  1. Inspect/palpate the external ears
  2. Weber test
  3. Rinne test
  4. Inspect ear canal
  5. Inspect tympanic membrane
53
Q

Assessment of the hair includes:

A
  1. Smooth, shiny, even consistency w/o evidence of breakage
  2. Hair amount
  3. Equal & symmetrically distributed
54
Q

Assessment of the nails includes:

A
  1. Capillary refill (>3 seconds)
  2. Condition of nails: tenting? 180 degrees? color?
  3. Grooming of nails

3306 Final (12 decks)

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