230 Test 2
Has anyone in your family had a recent illness, rash, or other skin problem or allergy? Describe.
Viruses (e.g., chickenpox, measles) can be highly contagious. Acne and atopic dermatitis tend to be familial. Some allergies may be identified from family history.
Lack of resilience or inelasticity of the artery wall may indicate
arteriosclerosis.
Flat, hollow, or less-rounded shoulders are seen with
dislocation.
Severe malnutrition in African American children may cause
copper-red hair color
Numbness or dulling of the sensations of pain, temperature, and touch to the feet may be seen in
diabetic peripheral neuropathy.
discrete lesion
distinct, individual lesions that remain separate
Obese clients often report
dry, itchy skin.
decreased skin mobility
edma
Cancerous lesions can be
either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma
Turgor refers to the skin's
elasticity and how quickly the skin returns to its original shape after being pinched.
Skin cancer risk factors
exposure to uv sunlight, tanning beds, fair complexion, work with tar, coal, pitch or creosote Sun exposure, especially intermittent pattern with sunburn; risk increases if excessive sun exposure and sunburns began in childhood. Intermittent exposure to the sun or UVR is associated with greatest risk for melanoma and for BCC, but overall amount of exposure is thought to be associated with SCC. SCC is most common on body sites with very heavy sun exposure, whereas BCC is most common on sites with moderate exposure (e.g., upper trunk or women's lower legs) Nonsolar sources of UVR Medical therapies such as PUVA and ionizing radiation Family or personal history and genetic susceptibility (especially for malignant melanoma) Moles, especially atypical lesions Pigmentation irregularities Fair skin Age; risk increases with increasing age Actinic keratoses Male gender Chemical exposure (arsenic, tar, coal, paraffin, some oils for nonmelanoma cancers) Human papillomavirus Xeroderma pigmentosum (rare, inherited condition) Long-term skin inflammation or injury (nonmelanoma) Alcohol intake (BCC); smoking (SCC) Inadequate niacin (vitamin B3) in diet Bowen disease (scaly or thickened patch) (SCC) Depressed immune system
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
fainting
Very warm skin may indicate a
febrile state or hyperthyroidism
Increased moisture or diaphoresis (profuse sweating) of the skin may occur in conditions such as
fever or hyperthyroidism.
The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. The nurse should instruct the client to
flex his elbow about 90 degrees.
A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up." The nurse should perform the McMurray test by asking the client to
flex the knee and hip while in a supine position.
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?
flexion
knee motions
flexion and extension
Dupuytren contracture
flexion contracture of fingers
Swelling above or next to the patella may indicate
fluid in the knee joint or thickening of the synovial membrane.
Yellow, thick, crumbling nails are seen in
fungal infections
Bacterial infections of nails cause
green, black, or brown nail discoloration.
Symptoms of peripheral vascular disease
heaviness of legs, aching sensation in legs aggravated by standing or sitting for long periods of time, leg edema, or varicosities.
Varicose veins
hereditary but may also develop from increased venous pressure and venous pooling (e.g., as happens during pregnancy). Standing in one place for long periods of time also increases the risk for varicosities.
An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of
herniated intervertebral disc
VESICLE example
herpes simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn.
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia.
Tenderness, edema, decreased ROM, and crepitus are seen
in hip inflammation and DJD.
On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n)
increased thoracic curve
Excessive generalized hair loss may occur
infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure chemotherapy or radiation therapy.
Patchy hair loss may result from
infections of the scalp, discoid or systemic lupus erythematosus, and some types of chemotherapy.
Raised lesions on scalp may indicate
infections or tumor growth
Patchy hair loss may accompany
infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.
Bursitis
inflammation of a bursa sac
tenosynovitis
inflammation of a tendon sheath, in fingers painful extension is seen
Osteomyelitis
inflammation of bone and bone marrow
Aspirin
inhibit platelet aggregation and also prolongs the time it takes for blood to clot and is used to reduce the risks associated with PVD
A complete peripheral vascular examination involves
inspection, palpation, and auscultation. Compare the client's arms and legs bilaterally. Better objective data can be gained by assessing a particular feature on one extremity and then the other.
The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing
intermittent claudication.
Pallor (loss of color)
is seen in arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.
Erythema (skin redness and warmth)
is seen in inflammation, allergic reactions, or trauma. In a dark-skinned client may be difficult to see. However, the affected skin feels swollen and warmer than the surrounding skin.
Rheumatoid arthritis pain
is varied and may feel burning, throbbing, occurs on both sides of the body, worsens after sitting for long periods, has inconsistent pattern of worse and less pain, and with a feeling of heat and soreness in joints
secondary lesions include
keliod developing from old scar
A nodule example is
keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma.
While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with
malignancy.
peripheral cyanosis results from
may be a local problem resulting from vasoconstriction.
Pentoxifylline (Trental)
may be prescribed to reduce blood viscosity, improving blood flow to the tissues, thus reducing tissue hypoxia and improving symptoms
flattening of the lumbar curvature
may be seen with a herniated lumbar disc or ankylosing spondylitis.
When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system?
neurological system
Ulcers with smooth, even margins
occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency.
A sedentary lifestyle increases the risk of
osteoporosis.
Exposure to 20 minutes of sunlight per day promotes the
production of vitamin D in the body
Contracture of the Achilles tendon can occur with
prolonged use of high-heeled shoes.
A plaque example is
psoriasis (psoriasis vulgaris pictured below) and actinic keratosis
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
pulse oximetry
Vascular lesions
reddish-bluish lesions, are seen with bleeding, venous pressure, aging, liver disease, or pregnancy.
Superficial vein thrombophlebitis is marked by
redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted
Risk factors for DVT include
reduced mobility, dehydration, increased viscosity of the blood, and venous stasis
Smoking cessation has the following benefits:
reduced workload on the heart, improved respiratory function, and reduced risk for lung cancer.
After cap refill test if There is slow (greater than 2 seconds) capillary nail bed refill (return of pink tone) look for
respiratory or cardiovascular diseases that cause hypoxia.
Firm, nontender, subcutaneous nodules in elbow may be palpated in
rheumatoid arthritis or rheumatic fever.
preparing the muscular exam
room is at a comfortable temperature and provide rest periods as necessary. Provide adequate draping to avoid unnecessary exposure of the client yet adequate visualization of the part being examined. Explain that you will ask the client frequently to change positions and to move various body parts against resistance and gravity. Clear, simple directions need to be given throughout the examination to help the client understand how to move body parts to allow you to assess the musculoskeletal system. Demonstrating to the client how to move the various body parts and providing verbal directions facilitate examination
A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by
scabies
Older clients may have skin lesions associated with aging, including
seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns.
Fissure is
secondary lesion Linear crack in the skin that may extend to the dermis and may be painful
Ulcer is
secondary lesion Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are possible.
SCAR (CICATRIX)
secondary lesion Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Young scars are red or purple, whereas mature scars (pictured below) are white or glistening
EROSION is
secondary lesion is Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area.
The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates
some impairment.
Koilonychia
spoon nails caused by anemia
when testing turgor more than 2 seconds suggests
suggests severe dehydration;
Pitting edema is associated
systemic problems, such as heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema). A 1+ to 4+ scale is used to grade the severity of pitting edema, with 4+ being most severe
Gangrene is evident wit
that are slow to heal, dry and shriveled skin that changes color from blue to black and eventually sloughs off, cold and numb skin; pain may or may not be present.
The McMurray test is used to determine
the presence of loose bodies in the knee and is performed by having the athlete lie face down with the affected knee at 90 degrees flexion and compressing downward on the injured leg.
tinel sign
to test for carpel tunnel, Tingling or shocking sensation experienced with test
Doppler ultrasound device transmits and receives ultrasound waves to evaluate blood flow. It works by
transmitting ultra high-frequency sound waves that strike red blood cells (RBCs) in an artery or vein. The rebounding ultrasound waves produce a whooshing sound when echoing from an artery and a nonpulsating rush when echoing from a vein. The strength of the sound is determined by the velocity of the RBCs. In partially occluded vessels, RBCs pass more slowly through the vessel, thus decreasing the sound. Fully occluded vessels produce no sound
Splinter hemorrhages in nails may be caused by
trauma
The nurse notes that a client with an anxiety disorder has a small patch of baldness behind the left ear. What should the nurse suspect as the reason for this hair inconsistency?
trichotillomania
Supination:
turning or facing upward
Eversion:
turning outward
eversion of foot
turning the sole of the foot outward
Osteoarthritis pain
usually begins in one set of joints and on one side of the body, with a feeling of pain deep in the joint, improving with rest but worsening with rainy weather, perhaps a sensation of bones grating together, with stiffness early in the morning improving with movement
A hematoma is a:
vascular lesion A localized collection of blood creating an elevated ecchymosis. It is associated with trauma.
Telangiectasis (venous star) is
vascular lesion Bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. It does not blanch when pressure is applied. It is secondary to superficial dilation of venous vessels and capillaries and associated with increased venous pressure states (varicosities)
A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?
venous insufficiency
Do you experience heaviness, an aching sensation in your legs aggravated by standing or sitting for long periods, leg edema, or varicosities?
Ask this to ID peripheral vascular disease
After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.)
Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?
Assist the client to walk as soon and as often as possible.
Observe gait.
Base of support Weight-bearing stability Foot position Stride and length and cadence of stride Arm swing Posture
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?
Calcium
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
Carotene
EDEMA ASSOCIATED WITH CHRONIC VENOUS INSUFFICIENCY
Caused by obstruction or insufficiency of deep veins Pitting, documented as: 1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit; gross edema in extremity Usually unilateral; may be bilateral Skin ulceration and pigmentation may be present
Why would nurse ask this For male clients: Have you experienced a change in your usual sexual activity? Describe.
Central arterial or venous disease may be manifested early as erectile dysfunction (ED). ED may occur with decreased blood flow or an occlusion of the blood vessels in one type of PAD known as aortoiliac occlusion (Leriche syndrome)
What is the rationale for asking the client whether he or she has noticed any new or changed moles?
Changes in existing moles or the appearance of new moles can indicate melanoma.
What should the nurse assess to test the function of the frontal lobe?
Communication
A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding?
Compare this finding to the range of motion to the right side
When determining a client's strength, it is necessary to implement what assessment?
Comparing one side to the other
Hirsutism (facial hair on females) is a characteristic
Cushing disease and polycystic ovary syndrome (PCOS) and results from an imbalance of adrenal hormones or it may be a side effect of steroids
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease
During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?
Diabetes
When assessing the gait pattern of a client diagnosed with Alzheimer disease, the nurse should expect to observe which finding?
Difficulty initiating a slow, shuffling gait
Do you have any birthmarks or moles? If so, please describe them. Have any of them changed color, size, or shape?
Establishing normal or baseline data allows future variations to be detected.
Use the following steps to measure ABI:
Have the client rest in a supine position for at least 5 minutes. Apply the blood pressure (BP) cuff to first one arm and then the other to determine the brachial pressure using the Doppler. First palpate the pulse and use the Doppler to hear the pulse. The "whooshing" sound indicates the brachial pulse. Pressures in both arms are assessed because asymptomatic stenosis in the subclavian artery can produce an abnormally low reading and should not be used in the calculations. Record the higher reading. Apply the BP cuff to the right ankle, then palpate the posterior tibial pulse at the medial aspect of the ankle and the dorsalis pedis pulse on the dorsal aspect of the foot. Using the same Doppler technique as in the arms, determine and record both systolic pressures. Repeat this procedure on the left ankle
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
Impetigo
A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?
Inability to wrinkle the forehead
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area
A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?
Legs should be elevated for 15 seconds
Retraction
Moving backward
Protraction
Moving forward
Have you had any change in the condition or appearance of your nails? Describe.
Nail changes may be seen in systemic disorders such as malnutrition or with local irritation (e.g., nail biting). Bacterial infections cause green, black, or brown nail discoloration. Yellow, thick, crumbling nails are seen in fungal infections. Yeast infections cause a white color and separation of the nail plate from the nail bed. It takes 6 months to totally replace a fingernail and 12 months to totally replace a toenail.
If you observe a lesion during inspection
Note symmetry, borders and shape, color, diameter of lesion, and change in lesion over time. Note its location, distribution, and configuration. Measure the lesion with a centimeter ruler. Normal skin has Stretch marks (striae), healed scars, freckles, moles, or birthmarks are common findings Freckles or moles may be scattered over the skin in no particular pattern.
PVD inspection
Observe arm size and venous pattern; also look for edema. Palpate the client's fingers, hands, and arms, gand note the temperature. Palpate to assess capillary refill time. Palpate the popliteal and femoral pulses. Palpate the radial and ulnar pulses. Inspect legs for distribution of hair, temperature, lesions, ulcers, or edema. Palpate the dorsalis pedal, and posterior tibial pulses. Inspect for varicosities and thrombophlebitis. Focused Specialty Assessment Palpate the brachial pulses if you suspect arterial insufficiency. Perform the Allen test. Palpate the epitrochlear lymph nodes. Palpate the superficial inguinal lymph nodes. Auscultate the femoral pulses. Perform position change test for arterial insufficiency. Determine ankle-brachial index (ABI). Perform manual compression test if the client has varicose veins. Perform Trendelenburg test if client has varicose veins.
TEMPOROMANDIBULAR TMJ joint motions
Opens and closes mouth. Projects and retracts jaw. Moves jaw from side to side.
ARTERIAL INSUFFICIENCY
Pain: Intermittent claudication to sharp, unrelenting, constant Pulses: Diminished or absent Skin characteristics: Dependent rubor Elevation pallor of foot Dry, shiny skin Cool-to-cold temperature Loss of hair over toes and dorsum of foot Nails thickened and ridged Ulcer characteristics: Location: Tips of toes, toe webs, heel or other pressure areas if confined to bed Pain: Very painful Depth of ulcer: Deep, often involving joint space Shape: Circular Ulcer base: Pale black to dry and gangrene Leg edema: Minimal unless extremity kept in dependent position constantly to relieve pain
A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?
Peripheral cyanosis
The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient?
Phalen's
A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?
Pinch a fold of skin on the client's forearm.
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?
Psoriasis
Which of the following risk factors for osteoporosis is the best predictor of low bone density?
Smoking
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
Spooning
MRSA risk factors
The greatest risk factor for MRSA is impaired skin integrity. Assess for Hospital-acquired MRSA Risk Factors Having an invasive medical device Residing in a long-term care facility Presence of a MRSA-positive person in the facility Assess for Community-acquired MRSA Risk Factors Participating in contact sports Sharing personal items such as towels or razors Suppression of the immune system function (e.g., HIV, cancer, or chemotherapy) Residing in unsanitary or crowded living conditions (dormitories or military barracks) Working in the health care industry Receiving antibiotics within the past 3 to 6 months Young or advanced age Men having sex with men Hemodialysis
Plantar flexion:
Toes point away from ankle
Internal rotation:
Turning of a bone toward the center of the body
Pronation:
Turning or facing downward
inversion of the foot
Turning the sole of the foot inward
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness.
Enlarged epitrochlear lymph nodes may indicate
an infection in the hand or forearm, or they may occur with generalized lymphadenopathy. Enlarged lymph nodes may also occur because of a lesion in the area.
Peripheral edema (swelling) results
an obstruction of the lymphatic flow or from venous insufficiency from such conditions as incompetent valves or decreased osmotic pressure in the capillaries. It may also occur with deep vein thrombosis (DVT). With leg or foot ulcers, edema can reduce tissue perfusion and wound oxygenation
Decreased ROM, swelling, tenderness, or crepitus may be seen in
arthritis
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
ashen.
Do you have any leg veins that are rope-like, bulging, or contorted?
ask for Varicose veins
To prepare for the skin, hair, and nail examination
ask the client to remove all clothing and jewelry and put on an examination gown. provide a long examination gown or robe. ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. ensure privacy by exposing only the body part being examined. Make sure that the room is a comfortable temperature. If available, sunlight is best for inspecting the skin. However, a bright light that can be focused on the client works just as well. Keep the room door closed or the bed curtain drawn to provide privacy as necessary. Explain what you are going to do, and answer any questions the client may have. Wear gloves when palpating any lesions because you may be exposed to drainage. Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client.
Which activities are focused on the assessment of chronic venous insufficiency of the lower extremities? Select all that apply.
assessing for brownish pigmentation of the skin assessing for pitting edema assessing for a history of incompetent venous system valves
The largest arteries of the upper extremities are the
brachial arterie
Redness, heat, and swelling of elwbow may be seen with
bursitis of the olecranon process due to trauma or arthritis.
Jaundice associated with
hepatic dysfunction.
OSTEOARTHRITIS
inflammation of the bone and joint causing nodes
dermatitis
inflammation of the skin
synovitis
inflammation of the synovial membrane that results in swelling and pain of the affected joint
Spoon nails (concave) may be present with
iron deficiency anemia
Sharp, knife-like pain occurs
most fractures and increases with motion of the affected body part
Prolonged immobility leads to
muscle atrophy.
Adequate protein in the diet promotes
muscle tone and bone growth
Bone pain is
often dull, deep, and throbbing
Abnormal sensations of tingling, pricking, or burning are referred to as
paresthesia
You would ask these questions why Do you experience pain or cramping in your legs? If so, describe the pain (aching, cramping, stabbing). How often does it occur? Does it occur with activity? Is the pain reproducible with same amount of exercise? If you have pain with walking, how far and how fast do you walk prior to the pain starting? Is the pain relieved by rest? Are you able to climb stairs? If so, how many stairs can you climb before you experience pain? Does the pain wake you from sleep?
peripheral arterial disease
feet with high arches
pes cavus
feet with no arches
pes planus or "flat feet")
Beau lines
white lines across the fingernails; usually a sign of systemic disease or injury
painful thickening of the skin over bony prominences and at pressure points
(corns)
when taking ABI (ankle brachial Make sure to use a correctly sized BP cuff. The bladder of the cuff should be Index)
20% wider than the diameter of the client's limb.
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
3
Which of the following wounds is most likely attributable to neuropathy?
A painless wound on the sole of the client's foot, which is surrounded by calloused skin
How would the nurse document normal muscle strength?
5/5
Which of the following clients is most likely at the greatest risk of acute compartment syndrome?
A 17-year-old who has just been fitted with an arm cast following a fracture of his radius
Recommended protective measures to avoid skin cancer include which of the following?
Avoiding sun exposure
Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward?
Brachial
To assess abduction of the shoulders and arms, a nurse should ask a client to do which of the following?
Bring both hands together overhead starting with the arms at the sides
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Broken with the presence of a blister
Which vessels return the lymph fluid to circulation?
Thoracic ducts
A nurse is working with a patient who has been confined to bed rest in the hospital for the past 2 weeks. Which areas of the body are most likely to develop ulcers due to arterial insufficiency? Select all that apply.
Tips of toes Toe webs Heels
During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?
Venous insufficiency
The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?
Venous insufficiency
Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?
Venous thromboembolism
When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?
Venous thromboembolism
A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?
Warm skin and brown pigmentation around the ankles
Bilateral edema usually indicates
a systemic problem, such as heart failure, or a local problem, such as lymphedema,
Extension:
Straightening a joint or increasing the angle between two bones
A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?
Osteomyelitis
A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency?
Pallor of foot occurs with elevation
Have you had any hair loss or change in the condition of your hair? Describe.
Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy. Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy. Certain medications can also contribute to hair loss. Also common with malabsorption syndromes, malnutrition, anorexia nervosa, and bulimia. Also common after gastric by-pass surgery. Hair loss is common in aging. The rate of hair growth slows and hair strands become thinner. Some hair follicles stop producing hair. A receding hairline or male pattern baldness may occur with aging.
ankle motions
Plantar flexion and dorsiflexion
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
Psoriasis, fungal infections, trauma
The client is experiencing septic shock. What assessment finding would the nurse expect to find?
Capillary refill greater than 2 seconds
A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?
Cervical strain
A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on?
Client's symptoms
Describe any difficulty that you have chewing. Is it associated with tenderness or pain?
Clients with temporomandibular joint (TMJ) dysfunction may have difficulty chewing and may describe their jaws as "getting locked or stuck." Jaw tenderness, pain, or a clicking sound may also be present with TMJ.
If the client has had a total hip replacement,
DO NOT TEST ROM UNLESS PHYSICIAN GIVES PERMISSION
During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
Existence of systemic diseases that have skin manifestations
A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?
Firmly compress the lower portion of the varicose vein
Have you ever been diagnosed with diabetes mellitus, sickle cell anemia, systemic lupus erythematosus (SLE), or osteoporosis?
Having diabetes mellitus, sickle cell anemia, or SLE places the client at risk for development of musculoskeletal problems such as osteoporosis and osteomyelitis. Type 1 diabetes increases risk of low bone density, and may increase fracture risk
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?
Hypothyroidism
Rough, flaky, dry skin is seen in
Hypothyroidism
positive phalen test
If symptoms (tingling, numbness, burning, or pain) develop within a minute with Phalen test, carpal tunnel syndrome is suspected.
Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system?
Inability to button the jacket due to swollen finger joints
When were your last tetanus and polio immunizations?
Joint stiffening and other musculoskeletal symptoms may be a transient effect of the tetanus, whooping cough, diphtheria, or polio vaccines
CLIENT EDUCATION for mersa
Keep wounds covered. Do not share personal items. Avoid unsanitary or unsafe nail care practices. If treatment has been started, do not stop until recovery is complete. Use Universal Precautions when touching others to avoid contact with contaminated body fluids. Wash your hands. Clean sports equipment between uses to avoid spread of infection. Wash clothes, sheets, towels, razors, and other personal items before and after use. Clean hands often.
A school age client has been diagnosed with genu valgum. What is the other name for this disease?
Knock kneed
Mary started a job 2 weeks ago that requires carrying heavy buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have?
Lateral epicondylitis (tennis elbow)
The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation?
Moderate strenuous exercise tends to increase bone density.
Bruits
abnormal "swishing" sounds heard over organs, glands, and arteries
lordosis
abnormal anterior curvature of the lumbar spine (sway-back condition)
induration
abnormal hard spots
Beau lines in nails occur
after acute illness and eventually grow out.
A generalized loss of pigmentation is seen in
albinism.
Secondary lesions
arise from changes in primary lesions.
Primary lesions
arise from normal skin due to irritation or disease.
Cool skin may accompany
arterial disease.
Dark-skinned clients may have in their nails
freckles or pigmented streaks in their nails.
example of macule
freckles, flat moles, petechiae, measles, scarlet fever
measure ROM with a
goniometer
A laterally deviated great toe with possible overlapping of the second toe and possible formation of an enlarged, painful, inflamed bursa (bunion) on the medial side is seen with
hallux valgus
thoracic kyphosis
hunch back
excessive perspiration
hyperhidrosis
Dull, dry hair may be seen with
hypothyroidism and malnutrition.
A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of
hypothyroidism.
Pale or cyanotic nails may indicate
hypoxia or anemia
Central cyanosis results from
cardiopulmonary problem
as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of
cranial nerve V (trigeminal nerve).
Inability to shrug shoulders against resistance is seen with a lesion of
cranial nerve XI (spinal accessory).
when testing turgor Recoil that occurs in less than 2 seconds suggests
moderate dehydration;
Muscle atrophy is seen with
nerve or muscle damage or lack of use.
Bluish cyanotic skin associated
oxygen deficiency.
intermittent claudication
pain and discomfort in calf muscles while walking; a condition seen in peripheral arterial disease
Slumped shoulders may result from
poor posture (especially while seated) or from depression.
Decreased moisture occurs with
dehydration or hypothyroidism
Decreased turgor (a slow recoil or return of the skin to its normal state) is seen in
dehydration.
Excessive scaliness of scalp may indicate
dermatitis
Acanthosis nigricans (AN), a linear streak-like pattern in dark-skinned people, suggests
diabetes mellitus.
Diuretics can alter
electrolyte levels, leading to muscle weakness
Examples of papules include
elevated nevi, warts, and lichen planus
Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.
pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin
VESICLE is
primary lesion Circumscribed elevated, palpable mass containing serous fluid. Vesicles are less than 0.5 cm
Infections of the hair follicle (folliculitis) appear
pustules surrounded by erythema
Cutaneous tag,
raised papule with a depressed center
Tenderness or pain over the epicondyles may be palpated in epicondylitis (tennis elbow) due to
repetitive movements of the forearm or wrists.
Cherry angiomas,
small red raised spots (1-5 mm wide) typically seen with aging.
A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints?
swelling warmth redness tenderness
Acute gouty arthritis
the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.
Regular exercise can also help to slow
the usual musculoskeletal changes, progressive loss of total bone mass (osteopenia/osteoporosis), and degeneration of skeletal muscle fibers (sarcopenia) that occur with aging.
Oral or transdermal contraceptives increase the risk for
thrombophlebitis, Raynaud disease, hypertension, and edema
Mobility of the skin refers to
to how easily the skin can be pinched.
A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve should the nurse document as being intact?
trigeminal
cherry angioma (vascular lesion)
vascular lesion Papular and round, red or purple lesion found on the trunk or extremities. It may blanch with pressure. It is a normal age-related skin alteration and usually not clinically significant.
spider angioma
vascular lesion Red arteriole lesion with a central body with radiating branches. It is usually noted on the face, neck, arms, and trunk.Compression of the center of the arteriole completely blanches the lesion. It is associated with liver disease, pregnancy, and vitamin B deficiency.
ECCHYMOSIS is
vascular lesion Round or irregular macular lesion that is larger than petechial lesion. The color varies and changes: black, yellow, and green hues. It is secondary to blood extravasation and associated with trauma and bleeding tendencies.
PETECHIA is
vascular lesion Round red or purple macule that is 1-2 mm in size. It is secondary to blood extravasation and associated with bleeding tendencies or emboli to skin.
Capillary refill time exceeding 2 seconds may indicate
vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.
Warm skin, edema and brown pigmentation around the ankles are associated with
venous insufficiency.
Prominent venous patterning with edema may indicate
venous obstruction
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's
vesicles.
Adduction
Movement towards midline of the body
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
Abdominal
A client diagnosed with rheumatoid arthritis exhibits edema, redness, and tenderness of the fingers. What is the nurse's priority action?
Administer prescribed anti-inflammatory
Do skin problems limit any of your normal activities?
Allergens (poison oak, poison ivy) may limit certain activities such as hiking, camping, and gardening. Moreover, exposure to the sun can aggravate conditions such as scleroderma. In addition, general home maintenance (e.g., cleaning, car washing) may expose the client to certain cleaning products to which the client is sensitive or allergic.
Upon assessing the skin, the nurse finds pustular lesions on on the face. The nurse identifies that these could be what?
Acne
ABCDEs of melanoma
Asymmetric, border irregular, color variance, diameter >0.6 cm, evolution
The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning?
Calf
Chronic Rheumatoid Arthritis
Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side
Circumduction
Circular motion
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying
toe motions
Flexion, extension, abduction, adduction
The nurse is going to assess a patient's ankle-brachial index. Which equipment will the nurse use for this assessment? (Select all that apply.)
Doppler device Blood pressure cuff
A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?
Dorsiflexion and plantar flexion
The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?
Dry and rough
example of ulcer
Examples include stasis ulcer of venous insufficiency (stasis dermatitis with venous stasis ulcer) and pressure ulcer.
When assessing the client's upper extremities, the nurse instructs the client to put the hands behind the neck with the elbows pointed laterally. This positioning facilitates assessment of which of the following functions?
External rotation of the shoulder
HALLUX VALGUS
Hallux valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side.
foot motions
Inversion and eversion
Hyperextension:
Joint bends greater than 180 degrees
A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?
Lower arm and hand for erythema and swelling
Cold fingers and hands, for example, are common findings with
Raynaud's.
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
The client has chronic hypoxia
Tinea corporis
ringworm
Carotene
the yellow pigment of the skin
Inversion:
turning inward
Has anyone in your family had skin cancer?
A genetic component is associated with skin cancer, especially malignant melanoma
Which cranial nerve controls pupillary constriction?
Oculomotor
CYST is
Primary lesion Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis.
PUSTULE is
Primary lesion Pus-filled vesicle or bulla. example is acne
A client's ankle-brachial index is 0.70. What should this finding suggest to the nurse about the client's peripheral vascular integrity?
there is borderline perfusion to the lower extremities
butterfly rash is characteristics
this is a characteristic of systemic lupus erythematosus (SLE).
MACULE is
this primary lesion is Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Macules are less than 1 cm with a circumscribed border
patch is
this primary lesion is a Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). greater than 1 cm, and may have an irregular border
GANGLION
Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist.
BULLA is
primary lesion Circumscribed elevated, palpable mass containing serous fluid. bullas are greater than 0.5 cm.
A plaque is
primary lesion Elevated, palpable, solid mass. are greater than 0.5 cm and may be coalesced papules with a flat top
Cold skin may accompany
shock or hypotension
Clammy skin is typical with
shock or hypotension.
When assessing muscle tone and strength, the nurse would document expected findings as
"upper and lower extremity muscle strength is 5/5 bilaterally"
Knees turn in with knock knees
(genu valgum)
knees that turn out with bowed legs
(genu varum)
During the physical assessment of the peripheral vascular system, a patient's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this patient is at risk for developing:
Arterial insufficiency ulcers
hip motions
Flexion with knee flexed and with knee extended Extension and hyperextension Circumduction Rotation (internal and external) Abduction Adduction
symptoms to intermittent claudication include:
A burning or aching pain in the feet and toes while resting, especially at night while lying flat Cool skin in the feet Redness or other color changes of the skin Increased occurrence of infection Toe and foot sores that do not heal
thumb motions
Flexion, extension, and opposition
finger motions
Flexion, extension, hyperextension, abduction, and circumduction
Palpate the tibiofemoral space
A patellofemoral disorder may be suspected if both crepitus and pain are present on examination.
wrist motions
Flexion, extension, hyperextension, adduction, radial and ulnar deviation
Risk factors for osteoporosis
Age Female gender Family history of osteoporosis Previous fracture Ethnicity Menopause/hysterectomy Long-term glucocorticoid therapy Rheumatoid arthritis Primary/secondary hypogonadism in men Modifiable risk factors (for osteoporosis and for fractures): Alcohol (greater than 2 drinks a day) Smoking (past or current history) Low body mass index (<20 kg/m2) Poor nutrition (low calcium intake and low protein intake) Vitamin D deficiency Eating disorders (leading to nutrition deficiencies) Low dietary calcium intake Insufficient exercise (especially sedentary lifestyle) Frequent falls
The student nurse learns that examining the skin can do all of the following except?
Allow early identification of neurologic deficits
When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should be added to the plan of care?
Altered tissue perfusion, arterial related to reduced blood flow
Are you experiencing any current skin problems such as rashes, lesions, dryness, oiliness, drainage, bruising, swelling, or changes in skin color? What aggravates the problem? What relieves it?
Any of these symptoms may be related to a pathologic skin condition. Swelling, bruises, welts, or burns may indicate accidents, trauma or abuse. If these injuries cannot be explained or do not match the symptoms, or the client's explanation seems unbelievable or vague, physical abuse should be suspected. Dry, pruritic skin; stretch marks, skin tags, dark patches, and skin infections are common in obese clients
Very thin skin may be seen in clients with
Arterial insufficiency or in those on steroid therapy
Perform Phalen test by
Ask the client to place the backs of both hands against each other while flexing the wrists 90 degrees with fingers pointed downward and wrists danglingHave the client hold this position for 60 seconds.
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test?
Ask the client to raise the leg to the point of pain and then dorsiflex the foot
Thenar atrophy
Atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome.
EDEMA ASSOCIATED WITH LYMPHEDEMA
Caused by abnormal or blocked lymph vessels Nonpitting Usually bilateral; may be unilateral No skin ulceration or pigmentation
TMJ dysfunction
Decreased ROM, and a clicking, popping, or grating sound, crepitis
Inability to extend the ring and little fingers is seen in
Dupuytren contracture
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?
Drooping of the left eye
During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing?
Effusion in the knee joint
The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?
Elevate the legs on pillows.
A nurse performs the Allen test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test
Ensure that the client's hand is not opened in exaggerated extension
A patient has developed an infection of the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area?
Epitrochlear
how to perform self skin exam
Examine head and face using one or both mirrors. Use a blow dryer to inspect scalp. Check hands, including nails. In full-length mirror, examine elbows, arms and underarms. Focus on neck, chest, torso. Women: check under breasts. With back to the mirror, use hand mirror to inspect back of neck, shoulders, upper arms, back, buttocks, legs. Sitting down, check legs and feet, including soles, heels, and nails. Use hand mirror to examine genitals.
A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?
Glossopharyngeal (IX)
A patient presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect?
Gouty arthritis
A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?
History of breast surgery
A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?
History of cigarette smoking
Wheal example
Hives, mosquito bite
Have you had any recent hospitalizations or surgeries?
Hospitalization increases the client's risk for a hospital-acquired infection, such as methicillin-resistant Staphylococcus aureus (MRSA) Major surgery or illness can cause temporary cessation of hair and nail growth.
HAMMER TOE
Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.
The following are guidelines for assessing joints and muscle strength:
Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle atrophy. Compare bilateral joint findings. Palpate for edema, heat, tenderness, pain, nodules, or crepitus. Compare bilateral joint findings. Test each joint's range of motion (ROM). Demonstrate how to move each joint through its normal ROM, then ask the client to actively move the joint through the same motions. Compare bilateral joint findings.
Do you have a family history of keloids?
Keloids are more common in skin of color (African, African-American, Asian descent) and in persons with a family history of keloids. Early studies indicate that keloids are more likely to form between ages 11 and 25, especially before age 18
ulnar deviation of wrist
Lateral movement of the wrist toward the ulna (little finger)
Clustered configuration
Lesions grouped together Ex. Herpes simplex
Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?
Make sure the temperature in the room is comfortable.
PAD symptoms include
Painful cramping in hip, thigh or calf muscles after certain activities, such as walking or climbing stairs (claudication) Leg numbness or weakness Coldness in lower leg or foot, especially when compared with the other side Sores on toes, feet, or legs that won't heal A change in the color of legs Hair loss or slower hair growth on feet and legs Slower growth of toenails Shiny skin on legs No pulse or a weak pulse in legs or feet Erectile dysfunction in men Pain occurs even at rest or when lying down (ischemic rest pain).Pain may be intense enough to disrupt sleep.Hanging legs over edge of bed or walking around room may or may not temporarily relieve pain.
Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome?
Percuss lightly on the inner aspect of the wrist
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?
Peripheral arterial disease
risks of pressure ulcers
Prolonged pressure to body, especially bony prominences Decreased/absent perception or sensation Decreased/absent mobility Increased moisture Increased/decreased nutrition Friction or shearing forces Fragile tissues and skin due to age, vascular incompetence, diabetes mellitus, or body weight (excessive or underweight)
Skin cancer education
Reduce sun exposure; seek shade. Always use sunscreen (SPF 15 or higher) when sun exposure is anticipated. Wear long-sleeved shirts and wide-brimmed hats. Wear sunglasses that wrap around. Avoid sunburns. Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers. Examine the skin for suspected lesions. If there is anything unusual, seek professional advice as soon as possible. Ensure that diet is adequate in vitamin B3
Risk assessment for PAD
Smoking Diabetes Obesity (a body mass index over 30) High blood pressure High cholesterol Increasing age, especially after reaching 50 years of age A family history of PAD, heart disease, or stroke High levels of homocysteine, a protein component that helps build and maintain tissue African American (more than twice as likely to have as non-Hispanic whites) People who smoke or have diabetes have the greatest risk of developing PAD due to reduced blood flow.
Are you taking any medications (prescribed or "over the counter"), using any ointments or creams, herbal or nutritional supplements, or vitamins? If so, how long have you been taking each of these?
Some medications can cause a photosensitivity reaction if the skin is exposed to UV light. It often appears 24 hours after taking the medication and leaves after discontinuing the medication. Some clients may exhibit allergic skin reaction(s)
For female clients: Are you pregnant? Are your menstrual periods regular? for skin/nails/hairs
Some skin and hair conditions can result from hormonal imbalance.
A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc?
Straight leg raise test
why would you ask this Are you experiencing any stress in your life at this time?
Stress increases the heart rate and blood pressure, and can contribute to vascular disease.
Do you wear support hose to treat varicose veins?
Support stockings help to reduce venous pooling and increase blood return to the heart.
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
Tinea corporis
Dorsiflexion
Toes draw upward to ankle
The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the patient?
Trendelenburg test
The radial pulse is palpated over the lateral flexor surface.
True
External rotation:
Turning of a bone away from the center of the body
Do you perceive yourself to have excessive perspiration?
Uncontrolled body odor or excessive or insufficient perspiration (excessive perspiration: hyperhidrosis) may indicate an abnormality of the sweat glands or an endocrine problem such as hypothyroidism or hyperthyroidism.
Which of the following veins drain into the superior vena cava? (Mark all that apply.
Upper torso Head Upper extremities
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
Urticaria or hives
Fibromyalgia
a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood changes, or cognitive disorders, is hard to diagnose
Mole (also called nevus),
a flat or raised tan/brownish marking up to 6 mm wide.
ankylosing spondylitis
a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae
Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from
a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy.
Seborrheic keratosis,
a warty or crusty pigmented lesion.
While assessing muscle strength in an older adult client, the nurse determines that the client's knee joint has a rating of 3 and exhibits active motion against gravity. The nurse should document the client's muscle strength as being/having
average weakness.
Lymphedema results from
blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.
While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is
blue
weight-bearing exercises are the only exercises that can promote
bone density.
Thickened nails (especially toenails) may be caused by
decreased circulation, and are also seen in onychomycosis.
Some nurses believe that using the ________ to assess moisture leads to a more accurate result.
dorsal surfaces
epitrochlear node
drains hand and lower arm
Pruritus (Itch) may be seen with
dry skin, drug reactions, allergies, lice, tinea, insect bites, uremia, or obstructive jaundice.
vitamin C promotes
healing of tissues and bones
lymphedema usually presents with
nonpitting edema of only one extremity, which causes induration, not ulceration, of the skin and shows no pigment changes.
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?
notched border diameter great than 6 cm asymmetry
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa.
Nutritional deficiencies may cause hair to develop
patchy gray
Examples of bulla include
pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?
popliteal
Preparing the Client for PAD exam
put on an examination gown and to sit upright on an examination table. Make sure that the room is a comfortable temperature (about 72°F), without drafts. This helps to prevent vasodilation or vasoconstriction. Before you begin the assessment, inform the client that it will be necessary to inspect and palpate all four extremities and that the groin will also need to be exposed for palpation of the inguinal lymph nodes as well as palpation and auscultation of the femoral arteries. Explain that the client can sit for examination of the arms but will need to lie down for examination of the legs and groin, explain in detail what you are doing and answer any questions the client may have. This helps to ease any client anxiety.
butterfly rash (also called Malar rash) is a
rash across the bridge of the nose and cheeks. this is a characteristic of systemic lupus erythematosus (SLE).
While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible
rotator cuff tear.
lymphedema is always
unilateral unless elephantiasis is diagnosed
Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle result from
venous insufficiency
verruca vulgaris
warts
Cyanosis may cause
white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas. Dark skin may appear blue, dull, and lifeless in the same areas.
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution
tips for muscle exam
Do not force the part beyond its normal range. Stop passive motion if the client expresses discomfort or pain. Be especially cautious with the older client when testing ROM. When comparing bilateral strength, keep in mind that the client's dominant side will tend to be the stronger side.
Do you regularly take medications prescribed by your physician to improve your circulation?
Drugs that inhibit platelet aggregation, such as aspirin (ASA) and/or clopidogrel (Plavix), may be prescribed to increase blood flow.
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?
Flexion
shoulder motions
Flexion and extension Abduction and adduction Circumduction Rotation (internal and external)
elbow joint motions
Flexion and extension of the forearm Supination and pronation of the forearm
BOUTONNIÈRE AND SWAN-NECK DEFORMITIES
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (boutonnière deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis.
For abnormal lesions,
For abnormal lesions, distribution may be diffuse (scattered all over) localized to one area, or in sun-exposed areas. Configuration may be discrete (separate and distinct), grouped (clustered), confluent (merged), linear (in a line), annular and arciform (circular or arcing), or zosteriform (linear along a nerve route)
presure ulcer unstageable
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.
pressure ulcer stage four
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomic location (see stage III). Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Primary lesions include
Macule, Papule, Plaque, Tumor, Urticaria, Vesicle, Bulla, Wheal, Cyst, Pustule
If the client complains of a "giving in" or "locking" of the knee, perform
McMurray test
A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee?
McMurray's
A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order?
Measure from the anterior superior iliac spine to the medial malleolus
A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?
Measure movement with a goniometer
To differentiate between central and peripheral cyanosis, look for
central cyanosis in the oral mucosa.
fissure example
chapped lips or hands and athlete's foot
Annular configuration
circular lesions
The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the
competence of the saphenous vein valves.
how do steroids impact bones
deplete bone mass, thereby contributing to osteoporosis
A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client for
depression.
ballottement test.
This test helps to detect large amounts of fluid in the knee.
Joint or muscle pain
described as aching, but has been differentiated between mechanical- and inflammatory-type pains
when testing turgor and more than 3 seconds is
described as tenting.
Allen test
determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery
kyphosis
excessive outward curvature of the spine, causing hunching of the back.
Acanthosis nigricans
is velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla.
tumor example
larger lipoma and carcinoma.
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that?
squamous cell carcinomas are most common on body sites with heavy sun exposure.
The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as
stage II
The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to
straighten the elbow
Generalized hair loss may be seen in
various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy
Short, pale, and fine hair that is present over much of the body is termed
vellus.
A rusty, ruddy, or brownish pigmentation (rubor) around the ankles indicates
venous insufficiency
A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?
"The area of cramping is close to the area of arterial occlusion."
Zosteriform lesion
(linear along a nerve route)
confluent lesions
(merged)
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
1-intact, firm skin with redness 2-ulceration involving the dermis 3-full-thickness skin loss 4-necrosis with damage to underlying muscle
Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person?
1.00
Test ROM of fingers
. Ask the client to (A) spread the fingers apart (abduction), (B) make a fist (adduction), (C) bend the fingers down (flexion) and then up (hyperextension), (D) move the thumb away from other fingers, and then (E) touch the thumb to the base of the small finger.
muscle strength is on a _____ scale
0-5 with 5 being normal
The nurse notes that a client's lower left leg swelling is alleviated when the extremity is elevated. Which stage of lymphedema is this client experiencing?
1
Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
A sebaceous cyst
Do you have a history of smoking and/or drinking alcohol? SHN
A significant association between cigarette smoking, alcohol consumption, and psoriasis has been found
A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?
Abdomen, noting any organ enlargement or tenderness
The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?
Allen test
Operating the Doppler ultrasound
Apply a fingertip-sized mound of lukewarm gel over the blood vessel to be assessed. At a 60- to 90-degree angle, lightly place the vascular probe at the top of the mound of gel. Listen for a whooshing (artery) or nonpulsating, rushing (vein) sound. Clean the skin with a tissue. Clean the probe as recommended by the manufacturer. Mark the site with a permanent pen for easy reassessment. Record findings.
The nurse is assessing blood flow in the lower extremities of a client. What should the nurse keep in mind when using a Doppler for this assessment? Select all that apply.
Apply warm gel to the areas on the extremity Apply steady but gentle pressure over the area Keep the extremity warm during the assessment
Ulcers associated with _______ are usually painful and are often located on the toes, foot, or lateral ankle.
Arterial disease
wrist exam flick signal
Ask the client, "What do you do when your symptoms are worse?" if the patient responds with a motion that resembles shaking a thermometer (flick signal), carpal tunnel may be suspected.
CLIENT EDUCATION to avoid pressure ulcers
Bathe with mild soap or other agent; limit friction; use warm not hot water; follow set bath schedule that is individualized. For dry skin: Use moisturizers; avoid low humidity and cold air. Avoid vigorous massage; avoid massage over bony prominences. Complete activity as directed. Take nutritional supplementation, as directed. Use incontinence skin cleansing methods as needed: gently clean skin of all moisture, urine, feces; avoid continued moisture and dryness with protective barrier products.
When assessing the foot and ankle of a clinic patient, the nurse notes that the patient complains of pain along the Achilles tendon. What might this patient have?
Bursitis
A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?
C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender
Have you noticed any change in your ability to feel pain, pressure, light touch, or temperature variations?
Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease. Decreased sensation may put the client at risk for developing pressure ulcers, impaired skin integrity, and skin infections.
The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?
Check feet daily for cuts or pressure areas.
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?
Check for a pulse, color, temperature, and capillary refill.
A client is experiencing left elbow pain. When assessing this joint, in which direction should the nurse move the extremity? Select all that apply
Extension Supination Pronation Flexion
shoulder motion numbers
Extent of forward flexion should be 180 degrees; hyperextension, 50 degrees; adduction, 50 degrees; and abduction 180 degrees.
Assess for the risk of falling backward in the older or handicapped client by performing the "nudge test." Stand behind the client and put your arms around the client while you gently nudge the sternum. bad result is
Falling backward easily is seen with cervical spondylosis and Parkinson disease.
pressure ulcer stage three
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?
Gouty arthritis
why does vein insufficiency cause brown spots
Hemosiderin Deposits. Hemosiderin is a brownish pigment caused by the breakdown of blood hemoglobin
A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?
Impaired Physical Mobility
A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?
Impaired Skin Integrity
The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?
Impaired physical mobility
epicondylitis
Inflammation of a tendon where it attaches to a bone
pressure ulcer stage one
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones.
Raynaud disorder
It is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours.
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Keloid formation at the site of an old incision
Abduction:
Moving away from midline of the body
VENOUS INSUFFICIENCY
Pain: Aching, cramping Pulses: Present but may be difficult to palpate through edema Skin characteristics: Pigmentation in gaiter area (area of medial and lateral malleolus) Skin thickened and tough May be reddish-blue in color Frequently associated with dermatitis Ulcer characteristics: Location: Medial malleolus or anterior tibial area Pain: If superficial, minimal pain; but may be very painful Depth of ulcer: Superficial Shape: Irregular border Ulcer base: Granulation tissue—beefy red to yellow fibrinous in chronic long-term ulcer Leg edema: Moderate to severe
A nurse palpates a weak left radial artery on a client. What should the nurse do next?
Palpate both radial arteries for symmetry.
pressure ulcer stage two
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury.
Are you experiencing any pain, itching, tingling, or numbness?
Pruritus may be seen with dry skin, drug reactions, allergies, lice, tinea, insect bites, uremia, or obstructive jaundice. Abnormal sensations of tingling, pricking, or burning are referred to as paresthesia. Numbness or dulling of the sensations of pain, temperature, and touch to the feet may be seen in diabetic peripheral neuropathy.
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Psoriasis
A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?
Pustular acne
Pustules with hair loss in patches are seen in
Pustules with hair loss in patches are seen in tinea capitis, a contagious fungal disease (ringworm,
Pressure ulcer rules for bed bound
Self-reposition every 15 minutes (chair) or 2 hours (bed). Use repositioning schedule. Use pressure mattress or chair cushion. Use lifting devices as directed to reduce shear (trapeze bar for patient; lifts for family, if necessary). Use positioning with pillows or wedges to avoid bony prominence contact with surfaces and to maintain body alignment; avoid donut-type devices. For those who are bed bound, avoid elevating head of bed beyond 30 degrees except for brief periods.
Do you recall having severe sunburns as a child?
Severe sunburns as a child are a risk factor for skin cancer
If the client has varicose veins, perform the
Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The client should lie supine. Elevate the client's leg 90 degrees for about 15 seconds or until the veins empty. With the leg elevated, apply a tourniquet to the upper thigh. Rapid filling is bad
Rotation:
Turning of a bone on its own long axis
A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?
Vitiligo
example of patch
Vitiligo and port wine mark
women at risk for osteoporosis
Women who begin menarche late or begin menopause early are at greater risk
lumbar hyperlordosis
___ is frequently associated with weak abdominals, tight hip flexors and tight back extensors
trichotillomania
a disorder characterized by the repeated pulling out of one's own hair
Yeast infections cause
a white color and separation of the nail plate from the nail bed.
Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with
arterial insufficiency
Marked pallor with legs elevated is an indication of
arterial insufficiency
Dark-colored toes and blisters are seen with
arterial insufficiency and gangrene
A cool extremity may be a sign of
arterial insufficiency.
An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of
fissures.
Freckles
flat melanized patches that vary with heredity and exposure to the sun
Regular exercise promotes
flexibility, muscle tone, and strength
Articulation between the head of the femur and the acetabulum is in the
hip joint.
Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from
hypoxia.
paronychia
infection around the nail, indicates local infection
Boutonnière deformity and swan-neck deformity are seen in
long-term rheumatoid arthritis
how does stair climbing weakness and sleep relate to PAD
lower tolerance for stair climbing predicted a higher mortality rate in people with PAD. Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. However, the lack of pain sensation may signal neuropathy in such disorders as diabetes. Reduced sensation or an absence of pain can result in a failure to recognize a problem or fully understand the problem's significance.
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for
lymphedema.
is often associated with delayed wound healing.
peripheral vascular disease
WHEAL is
primary lesion Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle).
A nodule is
primary lesion Elevated, solid, palpable mass that extends deeper into dermis than a papule. Nodules are 0.5-2 cm and circumscribed
A tumor is
primary lesion Elevated, solid, palpable mass that extends deeper into dermis than a papule. tumors are greater than 1-2 cm and do not always have sharp borders
a papule is
primary lesion an Elevated, palpable, solid mass. Papules have a circumscribed border and are less than 0.5 cm
Swelling, Tenderness and nodules in wrist may be seen with
rheumatoid arthritis
erosion example
rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, commonly called a canker sore, pictured below).
bursa sac
sac filled fluid between moveable structures to reduce friction
Snuffbox tenderness (the hollow area on the back of the wrist at the base of the fully extended thumb) may indicate a
scaphoid fracture, which is often the result of falling on an outstretched hand.
peripheral arterial disease (PAD)
symptoms do not appear until there is a 60% blockage intermittent claudication (pain caused by too little blood flow) is usually the first symptom and is characterized by weakness, cramping, aching, fatigue, or frank pain with activity; located in the calves, thighs, or buttocks but rarely in the feet. These symptoms are quickly relieved by rest but reproducible with same degree of exercise
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for
symptoms of stress.
Tenderness and warmth with a boggy consistency of knee may be symptoms of
synovitis
