Health Assessment Ch 14 Hair, Skin & Nails
chicken pox
varicella zoster virus
papule
A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size.
plaque
A plaque is an elevated, palpable, and solid mass that is greater than 0.5 cm and may be coalesced papules with a flat top.
Braden Scale
A tool for predicting pressure ulcer risk sensory perception, moisture, activity, mobility, nutrition, friction and shear
tumor
A tumor is an 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 nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client? Scoliosis Lordosis Unequal leg lengths Ankylosing spondylitis
Ankylosing spondylitis
Zollinger-Ellison
Gastrin-secreting tumor of pancreas (or intestine) acid → recurrent ulcers
Cholycystitis
Inflammation of the gall bladder RUQ Pain (Biliary colic) Nausea and vomiting Fever
How to palpate skin?
Palpate skin to assess texture/thickness/moisture Use the palmar surface of your three middle fingers to palpate skin texture.
Dorsiflexion
bending of the foot or the toes upward
McMurray Test
compression of the meniscus of the knee combined with internal and external rotation while the patient is face-up to assess the integrity of the meniscus
pustule
elevated, raised spot on the skin containing pus Pustules often acne pimple
clubbing of nails
finding in the nails that indicates chronic hypoxia, congenital heart disease CIGARETTE SMOKING
Which statement by a client about the skin needs validation by the collection of objective data by the nurse? "I had a small skin cancer removed about 3 years ago" Correct response: "My feet hurt and are always cold to the touch" "I have dry itchy skin in the winter"
"My feet hurt and are always cold to the touch" Pain and abnormal temperature of skin indicate further validation by nurse is required
terminal hair
(particularly scalp and eyebrows) is longer, darker, and coarser than vellus hair. Puberty initiates the growth of additional terminal hair in both sexes on the axillae, perineum, and legs.
Gait and posture assessment
- casual walking - heal to toe straight line - walk on toes - walk on heels does width of gate widen for balance? are they able to walk straight?
Vesicle
A vesicle is a circumscribed elevated, palpable mass containing serous fluid that is less than 0.5 cm.
Which test should a nurse perform on a client with ascites? A. Fluid wave test B. Murphy sign C. Psoas sign D. Obturator sign
A. Fluid Wave Test Murphy sign is used to test for cholecystitis, and the psoas sign and obturator signs are performed to test for appendicitis.
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border diameter great than 6 mm asymmetry
ALL notched border diameter great than 6 mm asymmetry
History of present health concern Select All that apply Abdominal pain COLDSPA; character (dull, aching; burning, gnawing; pressure; colicky; sharp, knifelike; variable) Indigestion Nausea and vomiting Appetite & Bowel elimination
Abdominal pain COLDSPA; character (dull, aching; burning, gnawing; pressure; colicky; sharp, knifelike; variable) Indigestion Nausea and vomiting Appetite & Bowel elimination
Which of the following terms is used to describe the arrangement of skin lesions? Generalized Exposed Annular Localized
Annular Explanation: Annular, or arciform, lesions are typical of the pattern and arrangement associated with tinea faciale. The terms exposed, localized, and generalized are not commonly used to describe the arrangement of lesions.
Joints
Areas where two or more bones join together Provide ROM
sternoclavicular joint
Articulation between the clavicle and the sternum
The nurse has the client participate in the assessment technique shown. For which health problem is the nurse assessing in this client? Kidney stones Distended bladder Small bowel obstruction Ascites
Ascites Explanation: Having the client place the hand midline on the abdomen while the nurse taps and palpates the other sides is a technique used to determine a fluid wave for the presence of ascites. This technique is not used to assess kidney stones, distended bladder, or for a small bowel obstruction.
hair color
Hair color varies and is determined by the type and amount of pigment (melanin and pheomelanin) production. A reduction in production of pigment results in gray or white hair. Produced by melanocytes at the hair papilla Determined by genes
Hair does not grow in which of the following areas?
Hair consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, labia minora, and penis.
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 Explanation: An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking.
Dermis
Inner layer - origin of sebaceous glands, sweat glands, and hair follicles.
Wrists, fingers, hips, knee, ankle and foot all have ________ for movement
Joints
freckles
MACULES - flat melanized patches that vary with heredity and exposure to the sun
Bouchard's nodes
Osteoarthritis (PIP swelling 2° to osteophytes)
Turgur
Palpate to assess mobility and turgor. Ask the client to lie down. Using two fingers, gently pinch the skin over the clavicle. Normally, the skin is mobile, with elasticity and returns to original shape quickly. Recoil is usually immediate. Immoblie indicates edema Slow recoil indicates dehydration
Which quadrant would you find liver pain?
RUQ
A client is concerned about a dark skin lesion on her anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion? Melanoma Supernumerary nipple Dysplastic nevus Dermatofibroma
Supernumerary nipple Explanation: This represents a supernumerary nipple. These occur along the "milk line" and do not exhibit features of more concerning lesions.
The abdominal wall allows normal compression during functional activities such as childbirth. True or False
True
appendix pain referral pattern
early epigastric, late right lower quadrant
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. ulceration involving the dermis necrosis with damage to underlying muscle full-thickness skin loss intact, firm skin with redness
intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle
mottled
spotted or blotched in coloring
abduction of shoulder
Abduct - bring away - To elicit abduction, the nurse should ask the client to bring both hands together overhead.
A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding? Severe weakness Poor range of motion Slight weakness Average weakness
Average Weakness
A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint? Epididymitis Chronic bacterial prostatitis (CBP) Orchitis Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH)
A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do? Prescribe a steroid cream to decrease inflammation. Consider admitting the client to the hospital. Reassure the parents and the client that this should resolve within 1 week. Tell him not to scratch them and follow up in 3 days.
Consider admitting the client to the hospital. Although this rash may not be impressive, the fact that they do not blanch with pressure is concerning. This generally means that there is pinpoint bleeding under the skin; while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. The nurse should always report this feature of a rash immediately.
Flexion
Decreases the angle of a joint (bending)
chicken pox
Fluid-filled lesions less than 1 cm in diameter Explanation: The rash of chicken pox is vesicles that are fluid-filled and less than 1 cm in diameter.
Psoas sign: pain in RLQ when leg hyperextended Obturator sign: pain in RLQ when hip and knee flexed and leg rotated internally and externally Murphy sign: pain when pressure applied under liver border of right costal margin and client inhales deeply Rovsing sign: pain in RLQ during pressure in LLQ Blumberg sign: pain or tenderness when tests for rebound tenderness by palpating deeply at 90 degrees into abdomen between umbilicus and anterior iliac crest
From Power Point
Which of the following should nurses teach all men, especially those who have had cryptorchidism? How to perform a testicular self-examination. Importance of regular monitoring of prostate-specific antigen (PSA) levels. Need for blood tests to measure serum acid phosphate levels. Need to undergo a baseline and follow up lymph node biopsies.
How to perform a testicular self-examination.
Rovising's sign
Pain in RLQ with palpation of LLQ indicative of appendicitis
shoulder joint
ball and socket
central cyanosis
decreased oxygenation, of the arterial blood in the lungs; Nurse should look for a bluish tinge of the Oral Mucosa
What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea diaphoresis
fainting Explanation: Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.
edema
Abnormal accumulation of fluid in interstitial spaces of tissues. puffy - The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched.
A 22-year-old law student comes to the office complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs, but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank around 14 drinks. Examination shows a young man appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? Acute cholecystitis Acute pancreatitis Biliary colic Peptic ulcer disease
Acute Pancreatitis
osteoblasts and osteoclasts
Bone building cells
An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) Texture Other lesions on body Depth Location Size
Location Size Texture Explanation: A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or the depth of the lesion.
pustular acne
Pustular acne Explanation: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.
Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? Herpes simplex Acne Psoriasis Varicella
Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex are vesicular lesions and psoriasis are plaque lesions.
Psoas sign
RLQ pain with extension of right thigh- HYPEREXTEDED indicative of appendicitis
The nurse is assessing a 79-year-old man who experienced an ischemic CVA 7 weeks prior and has a consequent loss of mobility. Because the client spends so much time immobilized, the nurse recognizes the importance of screening for pressure ulcers. Which of the following assessment findings would signal to the nurse an early sign of skin breakdown? Eschar on an area near a bony prominence Excessive sweating on a dependent body region Skin that feels boggy on palpation Loss of the dermis
Skin that feels boggy on palpation Explanation: Boggy skin consistency indicates a stage 1 pressure ulcer. Eschar and skin loss to the dermis would be noted in a more severe pressure ulcer; excessive sweating may constitute a risk factor but is not necessarily a sign of skin breakdown.
Connecting the skin to underlying structures is/are the
Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion? Papule Wheal Pustule Erosion
Wheal Explanation: A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. Erosion is a loss of superficial epidermis that does not extend to the
a) Kyphosis b) Lordosis c) Scoliosis
a) -exaggerated curvature of thoracic spine, common in older adults b) -exaggerated curvature of lumbar spine, common during toddler years & pregnancy c) -exaggerated lateral curvature
scaphoid abdomen
abnormally sunken abdominal wall, as with malnutrition or underweight
appendicitis
access for rebound pain rebound tenderness
adduction
adding to - Movement toward the midline of the body
Murphy sign is best described as: a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle. d. not a valid examination technique
b Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand
umbilicus
bellybutton - note color, contour, location midline center - palpate for bulging, swelling, masses
plantar flexion
bending of the sole of the foot by curling the toes toward the ground
Fibroadenoma
benign, a round, firm, rubbery mass that arises from excess growth of glandular and connective tissue in the breast
The epidermis contains no:
blood vessels or nerves consists of dead, keratinized cells that render the skin waterproof. almost completely replaced every 3 to 4 weeks. contains melanin
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: palms. sclera. oral mucosa. nail beds.
oral mucosa. Explanation: Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.
rebound tenderness (Blumberg's sign) is an indication of
pain when moderate palpation On the removal of the examiner's hand the patient should be again asked whether he or she is feeling pain or not. maybe appendicitis
aortic pulse
palpated in the epigastric area - for pulse
What are the two types of bone marrow?
red and yellow
erythema
redness of the skin harder to see in dark skinned ppl effected skin may feel warmer or swollen
The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 11 15 9 13
15 Explanation Add the numbers in each section to get the total: SENSORY PERCEPTION 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment MOISTURE 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist MOISTURE 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist MOBILITY 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation NUTRITION 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent FRICTION AND SHEAR 1. Problem 2. Potential Problem 3. No Apparent Problem
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: yellow. purple. blue. red.
Blue
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? Viral Exanthem Impetigo Psoriasis Herpes zoster
Impetigo Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthem is a macular or papular rash that is present along with a viral infection
The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?
Look for information from family and records regarding any problems that may have occurred at least 3 months ago. Explanation: These lines can provide valuable information about previous significant illnesses, some of which are forgotten or not able to be reported by the client. Because the fingernails grow at approximately 0.1 mm per day, the nurse would ask about an illness 100 days ago. This client may have been hospitalized for endocarditis or may have had another significant illness. Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a client's culture without good knowledge of that culture.
A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that which structures were injured by the burn? Select all that apply. Blood vessels Sweat glands Fat cells Lymphatic vessels Vernix
Lymphatic vessels Blood vessels Sweat glands The dermis is the layer of skin below the epidermis. The dermis is a well-vascularized, connective tissue layer containing collagen, elastic fibers, blood vessels, lymph vessels, and nerve endings. It is also the origin of sebaceous glands, sweat glands, and hair follicles. Fat cells are contained in the subcutaneous tissue. Vernix is a cheese-like substance comprised of shed epithelial cells and sebum that protects the infant's skin.
A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely? Seborrheic keratosis Actinic keratosis Squamous cell carcinoma Basal cell carcinoma
Seborrheic keratosis Explanation: This is a typical description for seborrheic keratosis. The stuck on appearance and rough wart-like texture are key features. These lesions often produce greasy scales when scratched with a fingernail, which further helps to distinguish them. Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish them to prevent unnecessary biopsy; however, it is important to consider biopsy whenever there is any doubt.
The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client? Skin self-examination Signs and symptoms of melanoma Recognizing different types of lesions Protection from sun damage
Signs and symptoms of melanoma Explanation: A simple method is to use the ABCDEs of melanoma detection: Asymmetry, Border irregularity, Color, Diameter of more than 6 mm, Evolution of lesion over time. The other given options are correct, but the most appropriate response is teaching about melanoma.
How should the nurse palpate the skin of a client to assess its texture? Pinch and roll the skin between the fingers Rub the dorsal surface of the hand over the skin Touch with the palmar surface of the three middle fingers. Press the fingertips to the skin surface
Touch with the palmar surface of the three middle fingers. The nurse should use the palmar surface of three middle fingers to assess skin texture in the client because these are most sensitive to texture. The palmar and dorsal surfaces of the hand are used to assess temperature. The dorsal or palmar surfaces of the hands and fingers are used to detect moisture on the skin. Fingertips are not used to palpate the skin.
The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin? epidermis dermis
dermis Explanation: The dermis is well supplied with blood. It contains connective tissue, sebaceous glands, sweat glands, and hair follicles. It is the apocrine sweat gland that is responsible for adult body odor. These glands are not present in any other skin layer.
skin
the largest organ of the body The physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation (UVR), and dehydration Vital role in temperature maintenance, fluid, and electrolyte balance, absorption, excretion, sensation, immunity vitamin D synthesis Provides individual identity Thicker on palms of hands and soles of feet Continuous with mucous membranes
What role does oxyhemoglobin play in the physiological process that results in pallor? the increase of blue pigment in the venous system the circulation of oxygen in the blood the reduction of red pigment in the arteries the loss of this component from the circulatory system
the reduction of red pigment in the arteries Explanation: Oxyhemoglobin, a bright red pigment, predominates in the arteries and capillaries. An increase in blood flow through the arteries to the capillaries causes a reddening of the skin (e.g., with blushing), whereas the opposite change usually produces pallor. Hemoglobin circulates in the red cells and carries most of the oxygen of the blood. An increased concentration of deoxyhemoglobin in cutaneous blood vessels gives the skin a bluish cast known as cyanosis. The loss of blood from the circulatory results in hemorrhage and hypotension.
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 alopecia tinea capitis hirsutism
trichotillomania Explanation: Trichotillomania or compulsive hair pulling is associated with a psychiatric disorder. Alopecia is a term used to describe general hair loss, most often associated with male pattern baldness, or a loss of hair from medications such as chemotherapy. Hirsutism is the appearance of hair on the face of a female. Tinea capitis causes round areas of alopecia on the scalp of a person with a fungus infection.
Where in the digestive tract is most of the water absorbed? Stomach Large intestine Ileum Duodenum
Large Intestine
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. the largest organ of the body. Helps make vitamin D in the body Protects against damage to the body from sunlight circulates blood throughout the body. Aids in maintaining body temperature Aides in the digestion of food.
Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature
vellus hair
Peach fuzz - pale, fine body hair of children and adult females
A 55-year-old woman with a history of type 2 diabetes went through menarche at age 19 and menopause 2 years ago. Which of the preceding is a risk factor for osteoporosis? Late menarche Postmenopausal status Late menopause Diabetes
Postmenopausal status
A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? psoriasis Beau's lines paronychia
Psoriasis
A client has a circumscribed, elevated, palpable mass containing serous fluid on the forearm. Which diagram should the nurse use to explain this mass to the client?
Small A vesicle is a circumscribed elevated, palpable mass containing serous fluid that is less than 0.5 cm
nudge test
Stand behind the client and put your arms around the client while you gently nudge the sternum
Barrett's esophagus
a condition that occurs when the cells in the epithelial tissue of the esophagus are damaged by chronic acid exposure -
Induration along the ventral surface of the penis suggests which of the following? Peyronie's disease Urethral stricture Testicular carcinoma Epidermoid cysts
Urethral stricture
palpate temperature
Use the dorsal surfaces of your hands
Braden Scale Scores
Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23
Lasegue test
[straight leg raising] helps confirm the presence of herniated nucleus pulposus. Lifting affected leg to see if sciatic pain is reproduced
Bulla
a large blister that is usually more than 0.5 cm in diameter containing watery fluid
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had: steroid therapy. radiation. chemotherapy. a recent illness.
a recent illness. Explanation: Beau's lines occur after acute illness and eventually grow out.
lordosis
abnormal anterior curvature of the lumbar spine (sway-back condition)
The lateral malleolus is found on the
fibula
gastroesophageal reflux disease (GERD)
back flow of contents of the stomach into the esophagus, often resulting from abnormal function of the lower esophageal sphincter, causing burning pain in the esophagus Cause - Pregnancy, Smoking, Obesity, hernia, eating too much, medications - laying down after eating - RAISE Head of Bed
Impetigo
bacterial inflammatory skin disease characterized by vesicles, pustules, and crusted-over lesions
Herbenden's nodes
bony nodules at the distal interphalangeal (DIP) joints
Phalen test and Tinel sign
both test for carpool tunnel -Phalen: hold both hands back to back while flexing wrist -Tinel: percussion of the median nerve at the wrist
To assess abduction of the shoulders and arms, a nurse should ask a client to: bring both hands in front of the body move the arms to the sides bring both hands together overhead move the arms forward
bring both hands together overhead
Phalen's test
carpal tunnel syndrome
gouty arthritis
inflammation and painful swelling of joints caused by excessive uric acid in the body
Correct order for abdominal assessment: palpation percussion auscultation inspection
inspection, auscultation, percussion, palpation
spooning of nails
iron deficiency
A client with a zosteriform rash has a rash that appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion is distributed equally on both sides of the body has lesions distributed over a large body area is distributed along a dermatome
is distributed along a dermatome Explanation: A zosteriform rash is distributed along a dermatome.
LLQ organs
large and small intestines
scolliosis
lateral curve--usually in thoracic vertebrae
RUQ organs
liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon
Types of bones and examples
long bones (most common)-humerus and femur short bones-carpals, tarsals, trapezius irregular bones-vertebrae flat bones- sternum, skull, scapula sesamoid- thumb, patella
Bone shapes
long, short, flat, irregular
Hyperextension
the extreme or overextension of a limb or body part beyond its normal limit
subcutaneous layer
the innermost layer of the skin, containing fat tissue adipose tissue layer under dermis - provides heat - cushion
peristaltic waves
waves of muscular contractions that propel contents from one point to another - move chyme
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
Psoas sign
pain produced with bending of the patient's knees to chest that may indicate appendicitis RLQ
Pronation
palm down
bursa
enclosed sac filled with viscous fluid located in joint areas of potential friction
TMJ
temporomandibular joint
Circumduction
the circular movement at the far end of a limb
Which statement by a client about the skin needs validation by the collection of objective data by the nurse? "I had a small skin cancer removed about 3 years ago" "I experience itchy and dry skin every winter" "My feet hurt and are always cold to the touch" "My port wine birth mark has not gotten any bigger"
"My feet hurt and are always cold to the touch" Explanation: A nurse needs to validate any subjective information that either does not fit with the rest of the information supplied by the client or any information that may indicate a problem exists. Cold feet that are painful need to be validated by careful assessment of the client's circulation. Dry and itchy skin is expected in the winter when the air is dry. Previous history of cancer and a port wine spot are past of the past medical history.
How many bones are in the human body?
206
How many vertebrae make up the spinal column? 31 32 33 37
33
Periosteum
A dense fibrous membrane covering the surface of bones (except at their extremities) and serving as an attachment for tendons and muscles.
ankylosing spondylitis
A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis. chronic, progressive arthritis with stiffening of joints, primarily of the spine
skeletal muscle
A muscle that is attached to the bones of the skeleton and provides the force that moves the bones. Assist with posture, produce body heat, allow body to move
The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? Acute pancreatitis Acute cholecystitis Biliary colic Acute diverticulitis
Acute pancreatitis
What ethnic group has a significantly higher incidence rate of prostate cancer? Caucasian African American Native American Asian
African American
flatus or flatulence
Air in the intestines that is passed through the rectum which can result in cramping or abdominal pain; also called gas
peptic ulcer
An open sore that forms in the lining of the esophagus, stomach, or small intestine Burning Sensation Cause (Controllable) NSAIDS, Smoking, Alcohol, Spicy Foods (Uncontrollable) H Pylori, Maybe a genetic link Zollinger-Ellison rare tumor
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply. Regular borders Asymmetrical Bleeding of a mole Itching Flat Change in size
Asymmetrical Change in size Itching Bleeding of a mole Explanation: Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs.
The nurse observes the client's lower extremities with many tattoos What should the nurse focus on when teaching this client about upcoming diagnostic tests? Inaccurate results when having a leg X-ray Burning when having an MRI Inaccurate Blood Glucose Level Allergy to dye for CT scan
Burning when having an MRI Explanation: A risk involved with tattooing includes burning sensations when undergoing magnetic resonance imagining (MRI). Tattoos does not affect x-rays, blood glucose levels, or response to dye injected for a CT scan.
Which skeletal muscle movement means "to move forward"? A. Abduction B. Flexion C. Protraction D. Eversion
C Protraction means moving forward. Abduction is moving away from the midline of the body. Bending the extremity at the joint and decreasing the angle of the joint is known as flexion. Moving outward is known as eversion.
Tendons
Connect muscle to bone
Which clinical manifestation should the nurse expect to find in a client with edema? Prominent blood vessels Decreased skin turgor Mottled skin tones Decreased skin mobility
Decreased skin mobility Explanation: The nurse may find decreased skin mobility in the client with edema. Skin mobility is assessed by gently pinching the skin on the sternum or under the clavicle using two fingers and determining how easily the skin can be pinched. Decreased skin turgor is seen in clients with dehydration. Prominent blood vessels are not seen with edema nor is the skin mottled. Mottling of the skin occurs when oxygenation is altered to the skin or tissues.
Dehydration
Decreased skin turgor is seen in clients with dehydration. An abnormally low amount of water in the body.
Hypothyroidism symptoms
Dry, coarse skin and brittle hair and cold intolerance. Swelling of face, hands, and legs.
Turgor
Elasticity of the skin
During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning? health promotion care risks for skin cancer skin ulcer formation Systemic disease that has skin manifestations
Existence of systemic diseases that have skin manifestations Explanation: One purpose of the integumentary health history is to identify systemic diseases that have skin manifestations. Questions to determine systemic diseases that the client may have include asking about prescribed medications, immunizations, and diagnosed illnesses. Such a history would provide little information regarding health promotion care, or risks for skin cancer or skin ulcer formation.
pallor
Extreme or unnatural paleness Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency.
What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply. Engage in regular, strenuous physical activity Increase the intake of fat in the diet Have children before 30 years of age Breast-feed if possible Regularly consume alcohol (two to five drinks daily)
Have children before 30 years of age Breast-feed if possible
When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes? High in the axillae at the top of the ribs Inside the lateral axillary fold Along the lateral edge of the scapulae Inside the upper arm
High in the axillae at the top of the ribs Explanation: The central axillary (midaxillary) nodes are palpable high up in the axillae at the top of the ribs. These nodes receive lymph from the lateral, posterior, and anterior axillary nodes. The anterior axillary (pectoral) nodes are located inside the lateral axillary fold along the pectoralis major muscle. The lateral axillary (brachial) nodes are located inside the upper arm along the humerus. The posterior axillary (subscapular) nodes lie inside the posterior axillary fold along the lateral edge of the scapulae.
During the breast examination of a client, the nurse notes an orange-peel or "peau d'orange" appearance of the skin of the breast. The nurse understands that this appearance of the skin is due to what type of breast condition? Paget's disease Fibroadenoma Fibrocystic lesions Metastatic disease
Metastatic disease Explanation: A pigskin-like or orange-peel appearance is found in metastatic disease of the breast. It results from edema caused by blocked lymphatic drainage.
You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. Moisture Admitting diagnosis Nutrition Age Activity
Moisture Activity Nutrition Explanation: The Braden Scale is a simple effective tool that evaluates levels of risk for ulcer development in the client. With its high reliability, predictive validity, and ease of use, the Braden Scale can be used to assess clients as often as every shift if needed. Six factors are rated using a matrix scoring system: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status.
peripheral cyanosis
Most often caused by poor circulation Best observed in the nail beds
Supination
Palm up
A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client? Chickenpox Pustular acne Bullous impetigo Cystic acne
Pustular acne Explanation: Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.
external rotation
Rotation of a joint away from the middle of the body.
During the inspection of a client's reproductive system, the nurse identifies small lacerations and bruises of the labia majora and minora. What does this finding suggest to the nurse? Sexual abuse Sexually transmitted infection Masculinization Pediculosis pubis
Sexual Abuse
The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document? Full thickness Dermal Superficial Superficial-dermal
Superficial Explanation: A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.
Heberden's nodes
Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis
The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? The client is demonstrating central cyanosis. The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood. The client's arterial blood will appear bluish when observed in the test tube. The cyanosis may be a result of a prolonged period of exposure to the cold.
The cyanosis may be a result of a prolonged period of exposure to the cold. Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a response to anxiety or a cold environment. The bluish color of a subcutaneous vein is not the trigger for this form of cyanosis.
Is the following statement true or false? Decreased estrogen levels after menopause increase the risk of osteoporosis.
True
Stomach cancer has association with Helicobacter pylori True or False
True
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? Papule Cyst Vesicle Wheal
Vesicle Explanation: The nurse should document the lesion as a vesicle. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Papules, wheals, and cysts are inappropriate terms. A papule is an elevated, palpable, solid mass with a circumscribed border. A wheal is an elevated mass with transient borders and no fluid cavity. A cyst is an encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis.
Assess abdomen
all 4 quadrants for Contour, shape, symmetry, and skin color Start in RLQ - RUQ - LUQ - LLQ (if patient states pain do that area last) Auscultate: to assess bowel sounds on each quadrant. for 1 full minute if no sounds heard listen for 5 minutes Percussion: Tympanny or hollow areas Dull over solid areas Palpate: abdomen gently for masses and area of tenderness Inspect the rectum: around the anus for lesions, discoloration, inflammation and hemmrrhoids
RLQ organs
cecum, appendix
Psoriasis
chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales
What is CBE? Frequency?
clinical breast examination (CBE) by a health care professional every 3 years for women ages 20 to 39 and every year for women age 40 and older.
paronychia
diseased state around the nail, infection
Macules
flat spots on the skin, such as freckles
elbow joint
hinge joint formed by humerus, ulna, and radius
kyphosis
hunchback
obturator sign
illicit abdominal pain by PASSIVE FLEXION AND INTERNAL ROTATION OF THE HIP appendicitis pain in RLQ when hip and knee flexed and leg rotated internally and externally
there is a genetic component with skin cancer, especially
malignant melanoma.
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) diameter great than 6 mm notched border asymmetry pink color
notched border diameter great than 6 mm asymmetry ABCDE stands for asymmetry, border, color, diameter and evolving. These are the characteristics of skin damage that doctors look for when diagnosing and classifying melanomas.
A nurse assesses a client with knee pain and observes swelling over the patella. This finding suggests which condition of the knee? effusion of the knee chondromalacia infrapatellar bursitis prepatellar bursitis
prepatellar bursitis
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 Changing position frequently moisture being allowed to accumulate on the skin shearing that occurs when sliding down in bed
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
internal rotation
rotation of the hip or shoulder toward the midline
A female client tells the nurse that she has pain while urinating. Besides obtaining a urinalysis, the nurse should assess the client for kidney trauma. sexually transmitted disease. tumors. infestation.
sexually transmitted disease.
wheal
small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions Hives
spongy and compact bone
spongyness deals with shock absorption and distributes it to the rest of the body, compact bone is strong and provides protection and support to the spongyness
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. usually there are precursor lesions for basal cell carcinomas. melanoma skin cancers are the most common type of cancers. African Americans are the least susceptible to skin cancers.
squamous cell carcinomas are most common on body sites with heavy sun exposure. Explanation: Squamous cell carcinoma is most common on body sites with very heavy sun exposure.
LUQ organs
stomach, spleen, pancreas, and large/small intestines
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:
stress
Striae
stretch marks
Oxyhemoglobin
the reduction of red pigment in the arteries Explanation: Oxyhemoglobin, a bright red pigment, predominates in the arteries and capillaries. An increase in blood flow through the arteries to the capillaries causes a reddening of the skin (e.g., with blushing), whereas the opposite change usually produces pallor.
musculoskeletal system
the system of bones and skeletal muscles that support and protect the body and permit movement
Ballotment Test
this test is more reliable when larger amounts of fluid are present. Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your right hand push the patella sharply against the femur. If no fluid is present, the patella is snug against the femur.
Eversion
turning the sole of the foot outward
