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Questions and Answers
What is one of the primary functions of the skin?
What is one of the primary functions of the skin?
Which condition is characterized by excessive dryness of the skin?
Which condition is characterized by excessive dryness of the skin?
What type of change would be noted in skin pigmentation that presents as an increase in color?
What type of change would be noted in skin pigmentation that presents as an increase in color?
Which of the following observations is essential for identifying pallor in dark-skinned individuals?
Which of the following observations is essential for identifying pallor in dark-skinned individuals?
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What subjective data might indicate a patient is experiencing issues with their integumentary system?
What subjective data might indicate a patient is experiencing issues with their integumentary system?
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What does pruritus refer to in skin assessment?
What does pruritus refer to in skin assessment?
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In terms of skin assessment, what is the significance of the term 'erythema'?
In terms of skin assessment, what is the significance of the term 'erythema'?
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What does cyanosis signify in terms of skin color change?
What does cyanosis signify in terms of skin color change?
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What is a potential nursing diagnosis related to changes in skin pigmentation?
What is a potential nursing diagnosis related to changes in skin pigmentation?
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In which condition is jaundice primarily observed?
In which condition is jaundice primarily observed?
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What nursing diagnosis is associated with the presence of erythema?
What nursing diagnosis is associated with the presence of erythema?
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Which of the following symptoms is NOT associated with cyanosis?
Which of the following symptoms is NOT associated with cyanosis?
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What should be noted first in a patient showing signs of jaundice?
What should be noted first in a patient showing signs of jaundice?
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What color change is primarily indicated by the condition erythrocyte hyperemia?
What color change is primarily indicated by the condition erythrocyte hyperemia?
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What nursing diagnosis corresponds with impaired tissue perfusion?
What nursing diagnosis corresponds with impaired tissue perfusion?
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Which clinical observation may indicate potential physical abuse?
Which clinical observation may indicate potential physical abuse?
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What is the first step to assess a skin lesion?
What is the first step to assess a skin lesion?
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Which of the following is NOT a primary characteristic used to describe skin lesions?
Which of the following is NOT a primary characteristic used to describe skin lesions?
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A zosteriform lesion is characterized by which of the following arrangements?
A zosteriform lesion is characterized by which of the following arrangements?
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What does asymmetry in the ABCDE mnemonic indicate?
What does asymmetry in the ABCDE mnemonic indicate?
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Which mnemonic summarizes the abnormal characteristics of pigmented lesions?
Which mnemonic summarizes the abnormal characteristics of pigmented lesions?
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Which type of lesion develops on unaltered skin and is present at the onset of disease?
Which type of lesion develops on unaltered skin and is present at the onset of disease?
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What type of lesion arrangement is characterized by lesions running together?
What type of lesion arrangement is characterized by lesions running together?
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Which of the following changes in a lesion should raise suspicion for malignant melanoma?
Which of the following changes in a lesion should raise suspicion for malignant melanoma?
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What describes an ulcer in terms of its characteristics?
What describes an ulcer in terms of its characteristics?
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Which of the following is NOT one of the six elements of the Braden Scale?
Which of the following is NOT one of the six elements of the Braden Scale?
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According to the Braden Scale, a score of 12 or less indicates what level of risk?
According to the Braden Scale, a score of 12 or less indicates what level of risk?
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What does a higher score on the Braden Scale indicate?
What does a higher score on the Braden Scale indicate?
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What is the maximum score one can achieve on the Braden Scale?
What is the maximum score one can achieve on the Braden Scale?
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Which condition correlates with a score of 6 on the Braden Scale?
Which condition correlates with a score of 6 on the Braden Scale?
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In the context of the Braden Scale, what does 'mobility' assess?
In the context of the Braden Scale, what does 'mobility' assess?
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What does the term 'friction and shear activity' refer to in the Braden Scale?
What does the term 'friction and shear activity' refer to in the Braden Scale?
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What is a characteristic of a stasis ulcer?
What is a characteristic of a stasis ulcer?
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What condition would likely display constant moisture according to the Braden Scale?
What condition would likely display constant moisture according to the Braden Scale?
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What does a nail base angle exceeding 180 degrees indicate?
What does a nail base angle exceeding 180 degrees indicate?
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What abnormal nail finding could indicate a cardiovascular or respiratory dysfunction?
What abnormal nail finding could indicate a cardiovascular or respiratory dysfunction?
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What does a capillary refill time longer than 2 seconds suggest?
What does a capillary refill time longer than 2 seconds suggest?
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What does the presence of transverse grooves in nails typically indicate?
What does the presence of transverse grooves in nails typically indicate?
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Which of the following is a sign of proper nail hygiene?
Which of the following is a sign of proper nail hygiene?
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What could dark brown or black pigmented areas on nails indicate in individuals with darker skin?
What could dark brown or black pigmented areas on nails indicate in individuals with darker skin?
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What does a nail that adheres well to the nail bed indicate?
What does a nail that adheres well to the nail bed indicate?
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What does a sluggish color return during capillary refill assessment indicate?
What does a sluggish color return during capillary refill assessment indicate?
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Study Notes
Integumentary System Assessment
- The integumentary system includes skin, hair, and nails, with critical functions such as protection, temperature regulation, and communication.
- Skin plays a vital role in wound healing, absorption and excretion, and production of Vitamin D.
Subjective Data Collection
- Assess for previous skin diseases, treatments, family history of allergies, and personal allergies to drugs, plants, or animals.
- Inquire about changes in pigmentation—conditions like vitiligo (hypopigmentation) and melasma (hyperpigmentation) are relevant.
- Monitor for changes in moles such as color, size, and shape, along with signs of pruritus (itching) or excessive dryness/moisture.
- Evaluate the patient’s medication history, as certain drugs can affect skin integrity.
Objective Data Collection
- Inspect skin color for general pigmentation and benign types such as freckles, moles, and birthmarks.
- Be attentive to widespread color changes, noting conditions such as pallor (sign of anemia), erythema (increased blood flow), cyanosis (decreased oxygenation), and jaundice (elevated bilirubin).
Color Changes Explained
- Pallor: Indicates reduced hemoglobin; assess conjunctiva and nail beds to evaluate anemia, especially in dark-skinned individuals.
- Erythema: Engorged capillaries seen with inflammation or fever; hyperemia elevates skin temperature.
- Cyanosis: Often found in mucous membranes; indicates potential respiratory or cardiac issues.
- Jaundice: Starts in the mouth and sclera; occurs with liver dysfunctions like hepatitis and cirrhosis.
Lesion Assessment
- Lesions classified by color, elevation, location, size, pattern, and texture (exudate).
- Differentiate between primary lesions (original) and secondary lesions (changes over time).
- Use the ABCDE criteria for pigmented lesions: Asymmetry, Border, Color, Diameter (greater than 6 mm), Elevation.
Braden Scale for Pressure Ulcer Risk
- Assesses risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
- Scoring: 15+ (low risk), 13-14 (moderate risk), 12 or less (high risk), below 9 (severe risk).
Nails Assessment
- Evaluate shape (look for clubbing), consistency (smooth, regular surfaces), and color (nail bed pink in healthy individuals).
- Capillary refill time indicates peripheral circulation; normal should be less than 2 seconds.
- Abnormal findings such as cyanotic nail beds and sluggish color return (>2 seconds) may indicate cardiovascular or respiratory dysfunction.
Nursing Diagnosis Examples
- Disturbed body image related to changes in pigmentation.
- Impaired tissue perfusion associated with pallor or altered oxygenation.
- Ineffective tissue perfusion as evidenced by delayed capillary refill time.
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Description
This quiz focuses on the integumentary system assessment, including the evaluation of skin, hair, and nails. Students will review both subjective and objective data collection methods. The content is designed to enhance understanding of the structure and function of the integumentary system in a clinical health context.
