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NUR |/ 216 |/Exam |/ 2 |/Study |/Guide |/QUESTIONS
|/WITH |/ANSWERS
Assessment |/techniques |/for |/integumentary |/- |/CORRECT |/ANSWERS |/✔✔inspection |/and |/palpation Inspection |/and |/palpation |/in |/skin |/color: |/expected |/findings |/- |/CORRECT |/ANSWERS |/✔✔-general |/pigmentation |/even |/and |/consistent -appropriate |/for |/each |/ethnicity: |/whitish |/pink |/for |/light |/or |/dark |/brown |/with |/yellow |/or |/olive |/tones -increased |/pigmentation |/if |/exposed |/to |/sun -hyperpigmentation: |/birthmarks, |/sun |/damage, |/freckles, |/tan |/lines. -HyPOpigmentation: |/scars, |/stretch |/marks, |/vitiligo. Inspection |/and |/palpation |/in |/skin |/color: |/unexpected |/findings |/- |/CORRECT |/ANSWERS |/✔✔pallor erythema cyanosis juandice pallor |/- |/CORRECT |/ANSWERS |/✔✔loss |/of |/color black |/skin |/tones |/are |/gray |/especially |/in |/mucous |/membranes.
Brown |/skin |/tones |/a |/change |/to |/yellow-brown. pale |/skin |/tones |/a |/loss |/of |/redness |/undertones best |/places |/to |/see |/are: |/conjunctivae, |/lips, |/buccal, |/and |/mucosa Causes: |/Anemia, |/shock, |/lack |/of |/blood |/flow Erythema |/- |/CORRECT |/ANSWERS |/✔✔redness hard |/to |/see |/on |/darker |/clients. face, |/skin |/and |/pressure |/sore |/areas. palpate |/skin |/for |/warmth |/and |/inflamed |/areas |/hard |/or |/tenderness causes: |/inflammation/infection, |/vasodilation(dilation |/of |/blood |/vessels, |/increases |/BP) Cyanosis |/- |/CORRECT |/ANSWERS |/✔✔light |/skin |/tones: |/bluish palms |/and |/soles |/for |/darker |/skin |/tones. brown |/skin |/tones |/change |/to |/a |/yellow. black |/skin |/tones |/look |/grey. best |/place |/to |/note |/in |/darker |/skin |/tones: |/mucous |/membranes |/and |/nail |/beds Causes: |/hypoxia |/or |/impaired |/venous |/return Juandice |/- |/CORRECT |/ANSWERS |/✔✔yellowing |/of |/the |/skin skin, |/sclera, |/mucosa |/membranes
-skin |/i |/shiny |/and |/taut -most |/common |/in |/legs -assess |/over |/a |/bony |/area -assess |/in |/all |/areas |/arms, |/legs |/and |/abdomen. +1 |/is |/trace |/2mm |/rapid |/return +2 |/is |/mild |/4mm |/10-15 |/second |/return +3 |/is |/moderate |/6mm |/prolonged |/return +4 |/is |/severe |/8mm |/prolonged |/return double |/amount |/for |/mm |/amount vascular |/lesions |/- |/CORRECT |/ANSWERS |/✔✔results |/from |/blood |/leaking |/from |/blood |/vessels |/into |/the |/dermis -Petechiae: |/infection |/or |/trauma. -Ecchymosis: |/trauma |/(collection |/of |/blood |/in |/dermis |/>3 |/mm |/in |/diameter, |/can |/change |/colors |/during |/healing |/(lead). |/ -purpura: |/infection |/or |/bleeding |/disorder note |/the |/following |/for |/lesions |/- |/CORRECT |/ANSWERS |/✔✔color height |/(above |/the |/skin) shape |/ size |/(measured |/in |/cm)
-location |/and |/distribution |/on |/the |/body, |/if |/any |/exudate |/note |/the |/color |/and |/odor. |/COCA |/(color, |/odor, |/consistency, |/amount) ABCDEs |/of |/melanoma |/- |/CORRECT |/ANSWERS |/✔✔A= |/asymmetry B= |/border |/(irregular) C= |/varies |/(brown, |/balck, |/tan) D= |/diameter |/(usually |/>6mm) E= |/evolving |/(looks |/different?) flat |/lesions: |/macule |/- |/CORRECT |/ANSWERS |/✔✔freckles, |/mole, |/measles, |/scarlet |/fever flat |/lesions: |/patch |/- |/CORRECT |/ANSWERS |/✔✔birthmark, |/vitiligo, |/hormonal |/changes raised |/lesions: |/papule |/- |/CORRECT |/ANSWERS |/✔✔wart, |/elevated |/mole, |/skin |/tags raised |/lesions: |/plaque |/- |/CORRECT |/ANSWERS |/✔✔psoriasis, |/eczema raised |/solid |/lesions: |/- |/CORRECT |/ANSWERS |/✔✔tumor |/(neoplasm) wheal |/(inspect |/bites, |/allergic |/reaction, |/hives nodule(melanoma)
pressure |/points |/for |/injuries |/- |/CORRECT |/ANSWERS |/✔✔Supine: back |/of |/head shoulder elbow butt heel Side |/laying |/(lateral): ear shoulder elbow hip thigh leg heel prone: elbow ribcage thigh knees toes
pressure |/injury: |/color |/of |/wound |/bed |/- |/CORRECT |/ANSWERS |/✔✔red: |/healthy |/regeneration yellow: |/infection, |/purulent |/drainage |/or |/slough black: |/eschar |/or |/necrotic |/tissue |/- |/requires |/removal |/for |/healing pressure |/injury: |/size |/of |/wound |/- |/CORRECT |/ANSWERS |/✔✔length, |/width, |/depth, |/undermining, |/tunneling pressure |/injury: |/exudate/drainage |/- |/CORRECT |/ANSWERS |/✔✔COCA pressure |/injury: |/surrounding |/skin |/- |/CORRECT |/ANSWERS |/✔✔intact, |/macerated, |/edematous, |/erythematous serosanguineous |/drainage |/- |/CORRECT |/ANSWERS |/✔✔mixture |/of |/serum |/and |/red |/blood |/cells Sanguineous |/drainage |/- |/CORRECT |/ANSWERS |/✔✔bloody |/drainage serous |/drainage |/- |/CORRECT |/ANSWERS |/✔✔clear, |/watery |/plasma purulent |/drainage |/- |/CORRECT |/ANSWERS |/✔✔thick |/green, |/yellow, |/or |/brown |/drainage
(osteomyelitis |/bone |/infection) unstageable |/- |/CORRECT |/ANSWERS |/✔✔ulcer |/is |/covered |/with |/slough |/or |/eschar |/ depth |/unknown deep |/tissue |/injury |/DTI |/- |/CORRECT |/ANSWERS |/✔✔discoloration |/but |/skin |/is |/INTACT damage |/to |/underlying |/tissue appears |/as |/a |/bruise |/with |/intact |/skin deeper |/discoloration Pressure |/injury |/management |/pearls |/- |/CORRECT |/ANSWERS |/✔✔S: |/surface |/should |/be |/smooth K: |/keep |/moving I: |/incontinence |/management N: |/nutrition |/(protein) pressure |/injury |/nursing |/interventions: |/- |/CORRECT |/ANSWERS |/✔✔-lift |/device -specialty |/mattress -assess |/every |/ 8 |/hours |/or |/per |/shift: |/braden |/scale -clean |/skin |/with |/warm |/water |/and |/little |/friction
-moisture |/barrier |/cream -nutrient |/dense |/foods: |/high |/protein |/diet -provide |/wound |/care |/per |/facility |/guidelines -prevention |/is |/key!! |/ -inspect |/everyday -ensure |/linens |/are |/clean |/and |/wrinkle |/free -reposition |/q2hrs |/or |/more, |/shift |/weight |/q15mins |/(chair) -limit |/chair |/time |/to |/ 1 |/hour
- |/keeping |/head |/less |/than |/ 30 |/degrees -float |/heels -ambulate |/- |/ROM hair |/care |/- |/CORRECT |/ANSWERS |/✔✔color |/and |/texture
- |/due |/to |/melanin |/productions -thick |/to |/fine -distribution |/(TANNER |/staging, |/pubic |/region) -evenly |/distributed -unexpected |/findings: |/lack |/of |/hair |/on |/legs |/- |/possible |/vascular |/disease: |/alopecia -lesions |/and |/infestations |/identify |/by |/looking |/at |/scalp |/and |/dividing |/hair |/into |/sections WEAR |/GLOVES
lotion |/as |/much |/as |/possible 12 |/cranial |/nerves |/nemonic |/- |/CORRECT |/ANSWERS |/✔✔oh: |/olfactory |/nerve-sense |/of |/smell oh: |/optic |/nerve- |/ability |/to |/see oh: |/oculomotor |/nerve-ability |/to |/move |/and |/blink |/your |/eye to: |/trochlear |/nerve-ability |/to |/move |/your |/eyes. tickle: |/trigeminal |/nerve- |/sensations |/in |/your |/face |/and |/cheeks |/tastes |/and |/jaw |/movement a: |/abducens |/nerve: |/ability |/to |/move |/your |/eyes females: |/facial |/nerve- |/facial |/expressions |/and |/sense |/of |/taste. vagina:vestibular |/nerve- |/sense |/of |/hearing |/and |/balance gave: |/glossopharyngeal |/nerve-ability |/to |/taste |/and |/swallow victor: |/vagus |/nerve-digestion |/and |/heart |/rate a: |/accessory |/nerve-shoulder |/and |/neck |/muscle |/movement hard-on: |/hypoglossal-ability |/to |/move |/your |/tongue tools |/for |/HEENT |/assessment |/- |/CORRECT |/ANSWERS |/✔✔penlight otoscope ophthalmoscope tongue |/blade stethoscope(diaphragm |/and |/bell)
cup |/of |/water gloves snellen |/chart 2 |/types |/of |/scents cranial |/bones |/- |/CORRECT |/ANSWERS |/✔✔frontal, |/parietal, |/temporal, |/occipital head |/neck |/and |/throat |/subjective |/data: |/what |/the |/patients |/tells |/you |/- |/CORRECT |/ANSWERS |/✔✔head |/pain/ |/headaches jaw |/tightness/pain neck |/pain/stiffness neck |/mass nasal |/congestion epistaxis(nose |/bleed) mouth |/lesions |/or |/mouth/dental sore |/throat hoarseness head/skull |/- |/CORRECT |/ANSWERS |/✔✔inspect |/first palpate |/next -note |/size, |/shape, |/symmetry |/and |/position
-if |/enlarged |/auscultate |/the |/thyroid |/for |/a |/bruit |/(bell: |/whooshing, |/blowing face: |/subjective |/data |/- |/CORRECT |/ANSWERS |/✔✔asymmetry |/of |/facial |/features, |/unequal |/movements -when |/did |/it |/begin? -are |/you |/having |/difficulty |/with |/your |/vision? |/blurry, |/double, |/blind |/spots? -difficulty |/swallowing? |/(NPO) |/nothing |/by |/mouthas -gradual |/onset |/or |/rapid? assessment |/of |/face: |/- |/CORRECT |/ANSWERS |/✔✔inspection |/and |/palpate -expected |/findings: |/symmetry |/of |/facial |/features; |/symmetry |/of |/expressions; |/no |/involuntary |/movements -unexpected |/findings: |/facial |/features |/asymmetric(paralysis |/of |/CN), |/lesions, |/erythema |/on |/the |/face(possible |/skin |/disorder/infection) |/periorbital |/edema |/(swelling |/around |/the |/eyes), |/tense |/facial |/expressions, |/hirsutism(women |/have |/excessive |/growth |/of |/dark |/coarse |/hair |/in |/manly |/spots) |/endocrine |/or |/hormonal |/disorder. facial |/drooping |/- |/CORRECT |/ANSWERS |/✔✔ask |/client |/to |/smile, |/show |/teeth, |/assess |/for |/unequal |/movement |/and |/absent |/of |/nasolabial |/fold(smile |/line) puff |/out |/cheeks
-press |/the |/cheeks |/and |/observe |/for |/equal |/air |/escaping |/from |/each |/side raise |/eyebrows open |/and |/close |/eyes |/hard |/as |/possible -orientation |/and |/comprehension?
- |/alert? |/speech? |/clear? |/using |/correct |/words? |/following |/commands? limb |/paralysis |/and |/awareness -lift |/and |/hold |/each |/arm |/and |/leg |/above |/the |/bed |/for |/ 10 |/secs |/atleast -touch |/their |/arms/legs |/bilateral |/(feel |/it?) -touch |/their |/finger |/to |/their |/nose -heel |/to |/shin -use |/of |/limbs |/on |/both |/sides? -vital |/signs, |/document |/findings |/and |/notify |/provider |/immediately |/if |/stroke |/is |/suspected(HIGH |/FALL |/RISK) -reorient |/client spot |/a |/stroke: |/FAST |/- |/CORRECT |/ANSWERS |/✔✔F: |/face |/drooping A: |/arm |/weakness S: |/speech |/difficulty T: |/time |/to |/call |/ 911
uvula: |/symmetrical |/rise elicit |/gag |/reflex mouth |/and |/throat |/expected |/findings |/- |/CORRECT |/ANSWERS |/✔✔expected |/findings: |/lips |/should |/be |/moist, |/symmetric |/and |/smooth -color: |/pink |/to |/plum/colored teeth: |/smooth |/and |/shiny mucosa: |/glistening, |/smooth |/and |/moist gums: |/moist |/and |/smooth -dark |/skinned |/can |/have |/patchy |/pigmentation tongue: |/moist |/and |/slightly |/rough, |/medium, |/red |/color hard |/palate: |/dome |/shape, |/whitish |/in |/color soft |/palate: |/smooth |/and |/light |/pink mouth/throat |/unexpected |/findings: |/- |/CORRECT |/ANSWERS |/✔✔tongue: |/swollen |/or |/dark |/red, |/thrush |/(white |/spots/yeast |/infection) gums: |/gingivitis |/(inflamed |/gums) hard |/palate: |/yellow |/discoloration |/(possible |/liver |/d/o, |/jaundice) uvula: |/erythema mucosa |/or |/lip: |/dry; |/painful |/round |/ulcer |/with |/a |/white |/base nose |/subjective |/data |/- |/CORRECT |/ANSWERS |/✔✔COCA
color, |/odor, |/consistency, |/amount any |/drainage pain? runny |/nose? nose |/and |/sinus |/assessment: |/- |/CORRECT |/ANSWERS |/✔✔inspect |/and |/palpate cranial |/nerve |/ 1 |/smell standard |/precautions |/and |/proper |/hand |/hygiene -assess |/nasal |/mucosa |/for |/color |/and |/integrity; |/opening |/of |/the |/nares -use |/penlight sinuses -frontal(upper) |/and |/maxillary(below) expected |/findings: |/ -no |/tenderness |/when |/palpating |/sinuses -nose |/is |/midline |/and |/symmetric -nasal |/mucosa |/is |/moist -nares |/are |/patent |/ unexpected |/findings: -tenderness |/with |/palpation |/of |/sinuses -pale |/mucosa |/with |/clear |/discharge= |/allergies -bright |/red |/mucosa=upper |/respiratory |/infection
