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A comprehensive set of questions and answers related to the nur 216 health assessment exam 2, covering topics such as skin assessment, pressure injuries, skull and face examination, neck assessment, eye examination, ear examination, and mouth examination. It includes detailed descriptions of various skin lesions, expected findings, and assessment techniques. Valuable for students preparing for the nur 216 health assessment exam 2.
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Brown pigmentation indicates venous insufficiency Shiny and translucent skin without hair indicates arterial insufficiency skin tugor locations adults-forearm or sternum infant- abdomen pallor
cyanosis Location- nail beds, sclera, MM Changes for light skin tones best located in sclera Changes for dark skin tones best located in hard palate indication - hypoxia, or imapired venous return jaundice Location- sclera, skin, MM Changes for light skin tones best detected in oral MM Changes for dark skin tones best detected in hard palate Indication- liver dysfunction, RBC destruction erythema Location- face, skin, trauma or pressure sore areas Indication- inflammation, localized vasodilation, substance use, sun exposure, rash or elevated body temperature
edema The accumulation of fluid in the tissues most often from direct trauma or imparied venous return Skin may appear tight and shiny Assess the swelling for discoloration, location, and tenderness Measure circumference in the extremities Evaluate pity by compressing the skin for at least 5 seconds over a bony prominence, the dept reflects the degree of edema edema rating 1+ trace, 2mm, rapid term 2+ mild, 4mm, 10-15 sec return 3+ moderate, 6mm, prolonged return 4+ severe, 8mm, prolonged term
primary lesions arise from healthy skin tissue macule Nonpalpable, skin color change, smaller than 1cm Freckle, petechiae papule Palpable, circumscribed, soiled elevation of the skin Elevated nevus nodule Palpable, circumscribed, deep, dirm 1 to 2 CM Wart vesicle
erosion Loss of epidermis, moist surface, no bleeding Ruptured vesicle crust Dried blood, serum or pus Scab scale Flakes of skin that exfoliate Dandruff, psoriasis, eczema fissure Linear crack Tinea pedia
ulcer Loss of epidermis and dermis with possible bleeding, scarring Venous stasis ulcer, pressure, ulcer Vascular lesion Result from blood leaking from blood vessels into the dermis Petechiae- infection or trauma Ecchymosis- trauma less than 3mm in diameter can change colors during healing purpura - infection or bleed disorder ABCDE of skin A = asymmetry B = border irregularity C = color variation D = diameter > 6 mm E = elevation (uneven surface)
stage 2 pressure injury Broken skin Breakdown of dermis and epidermis stage 3 pressure injury full thickness loss, looks like deep crater extend to fascia, subtaneous tissue damged/necrpticfat visable undermining/tunneling may be present damage to surrounding tissue stage 4 pressure injury Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. skull and face expected findings Normal size (normocephalic) No depressions, deformities, masses, or tenderness Symmetrical facial features, expressions Proportionate features (no acromegaly)
No involuntary movements CN V test trigeminal Motor- clench their teeth while you palpate the masseter, temporal muscle, and temporomandibular joint Sensory- have client close their eyes while you touch their face with a cotton ball, touch forehead, both cheeks, and chin CNVII test Facial Motor- test facial symmetry have patient smile, frown, puff out with cheeks, raise eyebrows, close eyes Neck (expected findings) muscles of the neck symmetric, shoulder equal in height and with average muscle mass
non painful, difficult to palpate and moveable Inspect trachea inspect the lower half of neck to see any enlargement, have the client hyperextend if necessary Instruct the client to take a sip of water and watch it move up down Palpate the thyroid gland on both sides of the trachea looking for size, masses, or smoothness Ascultae if enlarged inspect eyes Observe appearance of eyebrows, eyelashes, condition of eyes, color of sclera, eyelid drooping, or inflammation PERRLA Primary technique is inspection PERRLA P- pupils clear
E- equal and between 3-7mm in diameter R- round RL- reactive to light in both directly and consensually when you direct light into one pupil A- Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object Unexpected eye findings Loss of visual fields, asymmetric corneal light reflex, periorbital edema, conjunctivitis, or corneal abrasion visual acuity CNII Measures the clients ability to see small details Have clients use contact lenses/glasses during test includes snellen chart, Rosenbaum eye chart, Ishihara test snellen chart Screening for myopia (impaired far vision) Client stand 20 feet from chart Evaluate both eyes, then individual (covering the other)
Alignment- top of the ear equal with eyes Ear color matches face No lesions, deformities,lumps or tenderness No foregin bodies or discharge inspect ears internal Tympanic members is pearly gay and intact Light reflex is visible and well defined Cerumen might be present in the ear canal, moist cerumen brown to light gray Whisper test (CN VIII) Occlude one ear and test the other to see if the client can hear whisper sounds w/o seeing mouth move Rinne Test Place a vibrating tuning fork on top of the clients head. Have the client state when he can no longer hear the sound
Weber test test for sensorineural hearing loss Place a vibrating tuning for on top of the client head Ask the client if they hear it best from R/L of both ears sensorineural hearing loss hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness Conductive hearing loss causes Cerumen Foreign body Perforation of the tympanic membrane Edema Infection of the external ear or middle ear Tumor Otosclerosis
Hard/soft palate expected changes with aging (eyes) Decrease visual acuity Decreased peripheral vision Presbyopia expected changes with aging (ears) Hearing loss, loss of acuity for high-frequency tone Loss of acuity at all frequencies Cerumen accumulation Thickening of tympanic membrane expected changing in aging (mouth) Decrease sense of taste due to reduced number of taste buds Tooth loss Pale gums or gum disease
Decreased salivation
