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NSG 313 Exam 2 With Complete
Solution
Epidermis - ANSWER -Outer layer of skin -4 layers -basal cell layer (germinativum) -outer cell layer (corneum) Dermis - ANSWER -inner supportive layer -well vascularized, connective tissue layer that contains collagen, elastic fibers, nerve endings, lymph vessels -sebaceous glands -sweat glands subcutaneous tissue - ANSWER loose connective tissue layer that contains fat cells, blood vessels, nerves, remaining portion of sweat glands and hair follicles Pseudofolliculitis - ANSWER razor bumps or ingrown hairs after using a razor Skin assessment: color - ANSWER normal findings: evenly colored skin abnormal findings: pallor, cyanosis, jaundice, acanthuses nigricans cultural considerations: fair complex-> skin cancer risk older adult considerations: skin becomes pale die to decreased melanin production
Skin assessment: odors - ANSWER normal: slight to no perspiration abnormal findings: strong odor cultural considerations: most asians and American Indians; little to no body odor; whites and African Americans have strong body odor inuits: sweat more on face Skin assessment: color variations - ANSWER normal findings: suntanned, freckles abnormal: rash cultural considerations: light skinned have darker pigment around nipples, lips, gentalia Skin assessment: integrity - ANSWER normal: intact, no reddened areas abnormal: breakdown skin assessment: lesions inspection - ANSWER normal: smooth, no lesions, stretch marks abnormal: lesions older adult considerations: cutaneous tags skin assessment: texture - ANSWER normal: smooth and even abnormal: rough, flaky, dry skin, dry, itchy skin skin assessment: thickness - ANSWER normal: normally thin but calluses are common abnormal: very thin skin
stage 2 pressure ulcer - ANSWER partial thickness skin loss, open skin/breakdown, might see dermis stage 3 pressure ulcer - ANSWER full thickness tissue loss with visible fat, edges look rolled under stage 4 pressure ulcer - ANSWER Full-thickness tissue loss with exposed bone, tendon, or muscle deep tissue pressure injury - ANSWER deep red/maroon, skin stays intact unstageable pressure ulcer - ANSWER base of ulcer covered by slough and/or eschar in the wound bed. risk reduction in skin cancer - ANSWER examine the skin for suspected lesions using the ABCDE mnemonic to assess suspicious lesions ABCDE mnemonic for skin cancer assessment - ANSWER A: asymmetry (non-symmetrical) B: border C: color (multiple colors=bad) D: diameter (smaller is better, worry at more than 6 mm) E: evolution (changes over time) skin cancer risk factors - ANSWER -sun exposure -nonsolar sources of ultraviolet radiation -medical therapies -family history and genetic susceptibility
-moles -pigmentation irregularities -fair skin that burns and freckles easily; light hair -age -male gender -chemical exposure -human papillomavirus -long-term skin inflammation or injury -alcohol intake (BCC); smoking (SCC) -depressed immune system primary skin lesions - ANSWER macule, patch, papule, plaque, nodule, tumor, vesicle, bulla, wheal, pustule cyst secondary skin lesions - ANSWER Erosion, scar, ulcer, fissure vascular skin lesions - ANSWER petechia, ecchymosis, hematoma, cherry angioma, spider angioma, telangiectasis annual/circular lesion - ANSWER ex: ringworm confluent lesions - ANSWER smaller lesions that run together to form larger lesions ex: hives/eudicaria discrete lesions - ANSWER individual, distinct ex: multiple nevi (moles)
nodule/tumor - ANSWER Elevated, solid, palpable mass that extends deeper into dermis nodule: circumscribed and 0.5-2 cm (keloid, lipoma) tumor: >1-2 cm and do not always have sharp borders wheal - ANSWER elevated mass with transient borders that are often irregular. size and color vary. caused by movement of serous fluid into the dermis (hives, insect bites) vesicles/bulla - ANSWER Circumscribed, elevated, palpable mass containing serous fluid vesicle: <0.5 cm (herpes simplex, zoster, varicella) Bulla: >0.5 cm, thin walled rupture easily (contact dermatitis, blisters, poison ivy) cyst - ANSWER Encapsulated fluid-filled or semi-solid mass in the subcutaneous tissue or dermis or the subcutaneous layer ex: sebaceous cyst or epidermoid cyst pustule - ANSWER pus-filled vesicle or bulla (acne, impetigo) fissure - ANSWER linear crack in the skin that may extend into the dermis and may be painful ex: chapped lips/hands, athletes foot erosion - ANSWER loss of superficial epidermis, depressed, moist area ex: aphthous ulcer (canker sore) ulcer - ANSWER skin loss extending past the epidermis with necrotic tissue
loss and bleeding and scarring are possible ex: pressure ulcer, venous stasis ulcer scar - ANSWER skin mark left after healing of wound or lesion that represents replacement pf injured tissue with connective tissue hemangioma - ANSWER birthmark Petichiae - ANSWER broken blood vessels Telangiectasia - ANSWER spider angioma; alcohol abuse vellus hair (peach fuzz) - ANSWER short, fine, pale, and present over most of the body provides thermoregulation terminal hair - ANSWER longer, generally darker, course, protects scalp, filters dust and debris Folliculitis of the scalp - ANSWER Tines capitis - ANSWER ringworm of the scalp nails - ANSWER location: distal phalanges of fingers and toes hard, transparent plates, of keratinized epidermal cells grow from cuticle extends over entire nail bed with a pink tinge functions: protection, enhances movement of digits, allow fir extended grip nail clubbing - ANSWER deformity of the fingers and fingernails associated with a number of diseases, mostly cystic fibrosis, COPD, smokers, low oxygen
front of entire body pivot to right back to mirror hand held mirror: upper back and scalp sitting: cross leg over knee lymph nodes - ANSWER -filter lymph, a clear substance composed of excess tissue fluid -produce lymphocytes and antibodies -cluster appearance -<1 cm long -usually non palpable or feel like very small beads -consistency is soft -mobile -non-tender thyroid - ANSWER -largest endocrine gland -2 lobes connected by an isthmus -produces thyroid hormone which increases metabolic rate inspection of the head - ANSWER Normal findings: shape and size vary, especially with ethnicities, usually round, symmetric, erect, midline with no lesions, no involuntary movements abnormal findings: microcephaly, acromegaly, enlarged skull bones
inspection of the face - ANSWER normal findings: symmetric, round oval, elongated, or square appearance, no abnormal movements abnormal findings: asymmetry, drooping, weakness, paralysis, "mask-like" appearance (no expression) older adult considerations: facial wrinkles are prominent, lower face may shrink, mouth may be drawn inward inspection of neck - ANSWER normal findings: symmetric, no bulging masses abnormal findings: swellings, enlarged masses inspection of cervical vertebrae - ANSWER normal finding: c7 is prominent, visible, and palpable abnormal finding: prominence of other cervical vertebrae older client considerations: cervival curvature because of kyphosis "dowagers hump" inspection of neck ROM - ANSWER normal finding: smooth and controlled abnormal findings: muscle spasms, inflammation, stiffness, rigidity, limited mobility older client considerations: usually have decreased flexion, extension, lateral bending, and rotation of neck due to arthritis palpation of head - ANSWER normal findings: hard, smooth, no lesions abnormal findings: lesions or lumps palpating the temporal artery - ANSWER normal findings: elastic and bounding
other signs can include: numbness, confusion, trouble seeing, trouble walking, severe headache
acromegaly - ANSWER enlargement of the facial features
bells palsy - ANSWER begins suddenly one sided facial paralysis drooping eyelid
Eyes function - ANSWER transmits visual stimuli to the brain, the organ of vision
sclera - ANSWER white of the eye; protective covering, supports internal structures of the eye
Iris - ANSWER circular muscular disc containing color pigments, controlling size of pupil
lens - ANSWER encapsulated structure behind iris that bends the light rays onto retina
retina - ANSWER sends visual stimuli to the brain
rods and cones - ANSWER "photoreceptors" as they are responsive to light
external eye inspection normal findings - ANSWER -equal lid margins -no sclera seen above or below iris -eyes easily open and close -evenly distributed eyelashes -no redness, swelling, discharge, lesions -symmetric eyeballs -clear moist conjunctiva -transparent cornea iris round and evenly colored -pupil round and centered in iris
external eye inspection abnormal findings - ANSWER -ptosis (eye drooping) -failure of lids to close -redness and crusting -Hordeolum (infected sweat/tear gland) -chalazion
hyperopia - ANSWER farsighted; can see objects far away but not close up
presbyopia - ANSWER impaired near vision as a result of aging
assessing near visual acuity - ANSWER -jaeger card -used for clients with near vision or reading difficulty as well as middle-aged clients -if you have glasses keep them on -hold card 14 inches from eyes, cover one eye, repeat on opposite side -normal near vision: 14/14 in both eyes
confrontation test - ANSWER -tests peripheral vision -screens for glaucoma -stand 2 feet from client at eye level -both of you cover an eye (opposite eyes) and look directly at each other with uncovered eyes -slowly move a pen/finger in from four directions (inferior, superior, temporal, nasal) & have pt. say "now" when they see it normal: client can see examiners finger about the same time examiner sees it abnormal: loss of peripheral vision
Glaucoma - ANSWER -gradual loss of peripheral vision -damages the optic nerve caused by abnormally high intraocular pressure -2nd leading cause of blindness -ocular pain, headache, blurred vision
cover test - ANSWER -detects deviation in alignment for strength and deviation in eye movement -ask client to stare straight ahead and focus on a distant object -cover one of clients eyes with card -observe uncovered eye for movement -repeat on opposite side normal: uncovered eye remains fixed straight abnormal: phobia, strabismus or tropia
coral light reflex test - ANSWER -assess parallel alignment of eyes -hold penlight 12 inches from client -shine toward bridge of nose while client stares straight ahead -note light reflected on corneas normal: reflection of light on the cores should be in the exact same spot on each eye
Pupillary convergence - ANSWER as the client follows object toward their nose the eye follow and converge to look at object
Pupillary documentation: PERRLA - ANSWER P: pupils E: equal R: round R: reactive L: reactive to light A: reactive to accommodation
internal eye assessment normal findings - ANSWER -optic disc: round sharp well defined borders, creamy yellow-orange to pink -Retinal Vessels: arteries light red & smaller veins dark red & larger red reflex: easily visible, round, regular borders, orange fiery glow in pupil when shine light on pupil macula: darker area, located on temporal side of optic disk
internal eye assessment abnormal findings - ANSWER -optic disk: papilledema, optic atrophy -retinal vessels: constricted arterioles, dilated veins -red reflex: dampened or white reflex
-macula: clumped pigment with detached retinas
macular degeneration - ANSWER -major cause of visual impairment -causes deterioration of the macula, central area of the retina -damage to the macula leads to blind spots, blurred, distorted vision -risk factors: increasing age, gender (females more affected), family history, smoking, light eye color, hypertension, obesity, cardiovascular disease
cataract - ANSWER -clouding of the usually clear lens (like looking through foggy window) -gradually obstructs vision -cataracts causes black spots on red reflex
external ear - ANSWER -auricle or pinna (portion visible without any tools, conducts sound waves into external auditory canal) -external auditory canal(contains modifies sweat glands)
middle ear - ANSWER -small air-filled chamber in the temporal bone -separated from the external ear by the tympanic membrane (ear drum) -distinct landmarks of the tympanic membrane include the handle and short process of the malleus, umbo, cone of light, pars flaccida, pars tensa
