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Nurs 6700: Exam 1 Questions With Complete Solutions A thorough assessment of skin can reveal health status related to what aspects of health? (5 things) Oxygenation, circulation, nutrition, local tissue damage, and hydration. What is the general appearance and causes of cyanosis? Blue skin Heart or lung disease, cold environment What is the general appearance and causes of pallor? Paleness Anemia, shock What is the general appearance and causes of jaundice? Yellow-orange skin Liver disease, destruction of RBCs
What is the general appearance and causes of erythema? Redness fever, direct trauma, blushing, alcohol consumption Turgor Elasticity of the skin Indurated hardened skin Petechiae
ex. elevated nevus Nodule (description, size, and example) Elevated solid mass, deeper and firmer than papule 1-2 cm ex. wart Tumor (description, size, and example) Solid mass that extends deep through subcutaneous tissue larger than 1-2 cm ex. epithelioma
Wheal (description, size, and example) Irregularly shaped, elevated area or superficial localized edema varies in size ex. hive, mosquito bite Vesicle (description, size, and example) Circumscribed elevation of skin filled with serous fluid smaller than 1 cm ex. herpes Pustule (description, size, and example) Circumscribed elevation of skin similar to vesicle, but filled with pus varies with size
What is the cause of clubbing of the nails? chronic lack of oxygen; heart or pulmonary disease Which cranial nerves are utilized to perform the six directions of gaze test? CN III, IV, and VI What does PERRLA stand for? pupils equal, round, reactive to light and accommodation What should the lymph nodes in the head and neck feel like? Normally, lymph nodes are not easily palpable. Lymph nodes that are large, fixed, inflamed, or tender indicate a problem such as local infection, system disease or neoplasm. Tenderness almost always indicates inflammation.
What are risk factors for pressure ulcer development? (6) altered sensory perception for pain/pressure, impaired mobility, confusion/disorientation, shear force, friction, moisture What are the defining characteristics of stage 1 of pressure ulcers? reddened only, skin intact What are the defining characteristics of stage 2 of pressure ulcers? Loss of epidermis or dermis (may look like blister) What are the defining characteristics of stage 3 of pressure ulcers? Subcutaneous tissue involved (crater appearance) May see fat
What are the defining characteristics of the suspected deep- tissue injury stage of pressure ulcers? Suspected deep-tissue injury purple or maroon localized area discolored intact skin or a blood-filled blister painful firm/mushy boggy warmer/cooler difficult to detect in individuals with dark skin tones may begin as a thin blister over a dark wound bed can develop/progress rapidly What factors influence wound healing? (7 things) shear force friction moisture nutrition tissue perfusion infection age What are the common sites of pressure ulcer formation?
Supine Position: Occipital bone, scapula, spinous process, elbow, iliac crest, sacrum, ischium, achilles tendon, heel, sole of foot. Seated Position: Scapula, sacrum, ischium, posterior knee, sole of foot Lateral Recumbent (laying on side): Ear, shoulder, anterior iliac spine, trochanter, thigh, medial knee, lateral knee, posterior knee, lower leg, medial malleolus, lateral malleolus, lateral edge of foot What is debridement and what is the purpose of this procedure? Debridement is the removal of nonviable, necrotic tissue of a wound. The purpose is to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. What are the purposes of dressings?
Review the assessment techniques and abnormal findings for skin, hair, and nails Past history of skin disease, such as allergies, hives, psoriasis, and eczema. Change in pigmentation, Change in a mole, Excessive dryness or moisture, Pruritus, Excessive bruising, Rash or lesion, Medications, Hair loss, Change in nails, Environmental or occupational hazards, Self-care behaviors.
Review the assessment techniques and abnormal findings for head, face, and neck. Any unusually frequent or severe headaches? Any head injuries? Experiencing dizziness? Any neck pain? Any lumps or swelling? Any past surgeries on head or neck? Review the assessment techniques and abnormal findings for the eyes. Any difficulty seeing or blurring? Blind spots? Any eye pain? Any history of crossed eyes? Any redness or swelling? Any watering or excessive tearing? Any past injury, surgery, or history of allergies? Any past glaucoma tests? Do you wear glasses or contacts? Last vision test? Review the assessment techniques and abnormal findings for the ears. Any earache or other pain? Any ear infections? Any discharge? Any trouble hearing?
Be able to locate and label: suprasternal notch Angle of Louis point of maximal impulse where to place stethoscope to hear: aortic, pulmonic, tricuspid, mitral valves What is the function of the pleurae? serve as a lubricator so that the lungs may slide smoothly and noiselessly up and down during respiration What is the function of the trachea? transfers gases between environment and the lung parenchyma What is the function of the bronchi? Lined with goblet cells which secrete mucus that entraps the particles, and cilia, which sweep particles upward where they can be swallowed or expelled
What is the function of the alveoli? gas exchange Describe the process by which pregnant women experience an increase in both tidal volume and chest circumference during pregnancy. enlarged uterus elevates diaphragm vertical diameter of thoracic cage decreases horizontal diameter of thoracic cage increases total circumference of chest cage increases by 6cm 40% increase in tidal volume What is physiologic dyspnea? an increased awareness of the need to breathe What are factors that can increase risk for asthma? viral respiratory infections air pollution genetic susceptibility
lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax Where are the bronchial breath sounds heard? What do they sound like? over the trachea loud with high pitched/hollow quality Where are the bronchovesicular breath sounds heard? What do they sound like? posteriorly between scapulae, anteriorly over bronchioles blowing sounds that are medium pitched and of medium intensity Where are the vesicular breath sounds heard? What do they sound like?
over periphery of lung soft, breezy, low pitched List some strategies for performing a respiratory assessment on infants and children. let the parent hold an infant supported against the chest or shoulder; children may sit upright in parent's lap if sleeping, take the opportunity to inspect and listen to lung sounds to avoid crying during exam allow children to handle stethoscope to reduce fear of equipment and allow them to hear their own breath sounds tell children to "blow out" your penlight to promote a strong breath What are expected findings when auscultating a patient with atelectasis? Breath sounds decreased vesicular or absent over area. Voice sounds variable, usually decreased or absent over affected area.
