BSN211 Clinical Health Assessment - Week 3
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BSN211 Clinical Health Assessment - Week 3

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Questions and Answers

What is one of the primary functions of the skin?

  • Communication (correct)
  • Hair growth
  • Metabolism of nutrients
  • Production of red blood cells

    • Which condition is characterized by excessive dryness of the skin?

  • Seborrhea
  • Pruritus
  • Xerosis (correct)
  • Erythema

    • What type of change would be noted in skin pigmentation that presents as an increase in color?

  • Hyperpigmentation (correct)
  • Cyanosis
  • Hypopigmentation
  • Vitiligo

    • Which of the following observations is essential for identifying pallor in dark-skinned individuals?

    <p>Color of the lips and mucous membranes</p> Signup and view all the answers

    What subjective data might indicate a patient is experiencing issues with their integumentary system?

    <p>Change in mole characteristics</p> Signup and view all the answers

    What does pruritus refer to in skin assessment?

    <p>Itching sensation</p> Signup and view all the answers

    In terms of skin assessment, what is the significance of the term 'erythema'?

    <p>It signifies red patches on the skin</p> Signup and view all the answers

    What does cyanosis signify in terms of skin color change?

    <p>Decreased perfusion and reduced oxygenation</p> Signup and view all the answers

    What is a potential nursing diagnosis related to changes in skin pigmentation?

    <p>Disturbed body image related to color changes</p> Signup and view all the answers

    In which condition is jaundice primarily observed?

    <p>Increased amounts of bilirubin in the blood</p> Signup and view all the answers

    What nursing diagnosis is associated with the presence of erythema?

    <p>Disturbed skin integrity</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with cyanosis?

    <p>Warm skin on palpation</p> Signup and view all the answers

    What should be noted first in a patient showing signs of jaundice?

    <p>Sclera and oral mucous membrane</p> Signup and view all the answers

    What color change is primarily indicated by the condition erythrocyte hyperemia?

    <p>Erythema</p> Signup and view all the answers

    What nursing diagnosis corresponds with impaired tissue perfusion?

    <p>Decreased blood flow and oxygenation</p> Signup and view all the answers

    Which clinical observation may indicate potential physical abuse?

    <p>Multiple bruises above knees or elbows</p> Signup and view all the answers

    What is the first step to assess a skin lesion?

    <p>Inspect and palpate using gloves</p> Signup and view all the answers

    Which of the following is NOT a primary characteristic used to describe skin lesions?

    <p>Temperature</p> Signup and view all the answers

    A zosteriform lesion is characterized by which of the following arrangements?

    <p>Linear arrangement along a nerve route</p> Signup and view all the answers

    What does asymmetry in the ABCDE mnemonic indicate?

    <p>The lesion has an irregular shape</p> Signup and view all the answers

    Which mnemonic summarizes the abnormal characteristics of pigmented lesions?

    <p>ABCDE</p> Signup and view all the answers

    Which type of lesion develops on unaltered skin and is present at the onset of disease?

    <p>Primary lesion</p> Signup and view all the answers

    What type of lesion arrangement is characterized by lesions running together?

    <p>Confluent</p> Signup and view all the answers

    Which of the following changes in a lesion should raise suspicion for malignant melanoma?

    <p>A new pigmented lesion develops</p> Signup and view all the answers

    What describes an ulcer in terms of its characteristics?

    <p>Irregular shape with potential bleeding</p> Signup and view all the answers

    Which of the following is NOT one of the six elements of the Braden Scale?

    <p>Pain perception</p> Signup and view all the answers

    According to the Braden Scale, a score of 12 or less indicates what level of risk?

    <p>High risk</p> Signup and view all the answers

    What does a higher score on the Braden Scale indicate?

    <p>Decreased risk for pressure ulcers</p> Signup and view all the answers

    What is the maximum score one can achieve on the Braden Scale?

    <p>24</p> Signup and view all the answers

    Which condition correlates with a score of 6 on the Braden Scale?

    <p>Severe risk</p> Signup and view all the answers

    In the context of the Braden Scale, what does 'mobility' assess?

    <p>Ability to change one's position</p> Signup and view all the answers

    What does the term 'friction and shear activity' refer to in the Braden Scale?

    <p>Resistance of skin layers sliding over each other</p> Signup and view all the answers

    What is a characteristic of a stasis ulcer?

    <p>Associated with poor circulation</p> Signup and view all the answers

    What condition would likely display constant moisture according to the Braden Scale?

    <p>Very moist</p> Signup and view all the answers

    What does a nail base angle exceeding 180 degrees indicate?

    <p>Chronic hypoxia</p> Signup and view all the answers

    What abnormal nail finding could indicate a cardiovascular or respiratory dysfunction?

    <p>Cyanotic nail beds</p> Signup and view all the answers

    What does a capillary refill time longer than 2 seconds suggest?

    <p>Cardiovascular or respiratory dysfunction</p> Signup and view all the answers

    What does the presence of transverse grooves in nails typically indicate?

    <p>Nutrient deficiency</p> Signup and view all the answers

    Which of the following is a sign of proper nail hygiene?

    <p>Smooth and clean edges</p> Signup and view all the answers

    What could dark brown or black pigmented areas on nails indicate in individuals with darker skin?

    <p>Possible abnormality</p> Signup and view all the answers

    What does a nail that adheres well to the nail bed indicate?

    <p>Normal consistency</p> Signup and view all the answers

    What does a sluggish color return during capillary refill assessment indicate?

    <p>Cardiovascular distress</p> Signup and view all the answers

    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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    Related Documents

    BSN211 Clinical Health Assessment - Integumentary System PDF

    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.

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