Nursing Assessment Basics

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Questions and Answers

What characterizes a hemangioma known as a port wine stain?

Flat macular patch that blanches with pressure

Irregularly shaped spongy mass of blood vessels

Large flat dark red, bluish, or purplish patch (correct)

Raised red area with well-defined borders

Which of the following types of vascular lesions typically disappears by age 5-7?

Purpura

Strawberry mark (correct)

Telangiectasia

Cavernous hemangioma

What is the appearance of telangiectasia?

Tiny hemorrhages that blanch with pressure

Patches of purpura resulting from minor trauma

Permanently enlarged and dilated blood vessels (correct)

Port wine stain with a raised border

Why might venous lakes commonly occur in older populations?

From blood leaking out of smaller blood vessels Signup and view all the answers

What defines petechiae in terms of size and appearance?

Tiny, round, discrete spots ranging from 1-3 mm Signup and view all the answers

Which of the following vascular lesions are associated with a low blood platelet count?

Purpuric lesions and Petechiae Signup and view all the answers

What is the typical appearance of a star angioma?

Fiery red star shape with a solid center circle Signup and view all the answers

What condition may lead to the development of purpura in older individuals?

Minor trauma resulting in bleeding under the skin Signup and view all the answers

What distinguishes a patch from a macule?

A patch is larger than 1 cm in diameter. Signup and view all the answers

Which of the following is an example of a papule?

Elevated mole Signup and view all the answers

What is a key characteristic of a wheal?

It is superficial, raised, and transient. Signup and view all the answers

Which lesion is characterized by encapsulated fluid within the dermis?

Cyst Signup and view all the answers

What defines a bulla?

It is greater than 1 cm in diameter and contains clear fluid. Signup and view all the answers

Which lesion typically develops from a primary lesion over time?

Cyst Signup and view all the answers

How is a nodule defined?

A solid, elevated lesion greater than 1 cm. Signup and view all the answers

What is a common example of urticaria?

Allergic reaction Signup and view all the answers

Which of the following is a characteristic of a pustule?

Filled with pus Signup and view all the answers

Which primary skin lesion is identified by a solid, elevated, flat area greater than 1 cm?

Plaque Signup and view all the answers

Which of the following characteristics are part of the ABCDE criteria for evaluating pigmented lesions?

Elevation and evolution Signup and view all the answers

What describes lesions that are distinct and individual, remaining separate from each other?

Discrete Signup and view all the answers

Which shape of skin lesion is characterized by lesions that resemble concentric rings?

Target Signup and view all the answers

In terms of distribution, what term describes lesions that are confined to a specific area of the body?

Localized Signup and view all the answers

What is the significance of a diameter greater than 6mm in pigmented lesions?

It indicates potential malignancy. Signup and view all the answers

Which of the following shapes is characterized by a linear arrangement of lesions along a nerve root?

Zosteriform Signup and view all the answers

What type of exudate should be assessed when examining skin lesions?

Color and/or odor Signup and view all the answers

Which lesion configuration is described as lesions merging together?

Confluent Signup and view all the answers

What is the significance of assessing the patient's baseline skin characteristics before a skin examination?

It allows for a more thorough evaluation by recognizing individual variations. Signup and view all the answers

What does a capillary refill time of more than 3 seconds indicate?

Poor blood flow and possible dehydration. Signup and view all the answers

Which color change is indicative of cyanosis?

Bluish discoloration. Signup and view all the answers

What skin condition can be caused by trauma, bleeding disorders, or liver dysfunction?

Vascularity or bruising. Signup and view all the answers

What finding might suggest abuse when assessing bruises?

Discrepancy in bruise color and the reported time of injury. Signup and view all the answers

What does increased skin thickness typically indicate?

Poor tissue perfusion. Signup and view all the answers

What should be assessed in terms of hair distribution during a skin examination?

Presence of lice or excessive hair. Signup and view all the answers

What type of skin condition is characterized by edema when your thumb leaves a dent in the skin?

Pitting edema. Signup and view all the answers

When assessing for lesions, which factor should be considered?

All of the above. Signup and view all the answers

What is the expected finding when inspecting the nails for consistency?

They should feel firm upon palpation. Signup and view all the answers

Which of the following is NOT a common environmental factor affecting skin assessment?

Blood type. Signup and view all the answers

What is the primary reason for assessing hidden areas of the skin, such as skin folds?

To check for skin infections or irritation. Signup and view all the answers

What does the presence of erythema indicate?

Excess blood in the dilated superficial capillaries. Signup and view all the answers

What is the best location to assess skin elasticity?

Anterior aspect of the chest under the clavicle. Signup and view all the answers

Which level of consciousness is characterized by a patient that is difficult to arouse and is confused after waking?

Obtunded Signup and view all the answers

During a quick neuro check, what is the primary motor response that is typically assessed?

Gripping the hands and pushing feet against palms Signup and view all the answers

What does the presence of lanugo in infants indicate regarding their skin development?

It is a normal developmental stage Signup and view all the answers

What is a common skin change experienced by pregnant individuals that can fade after pregnancy?

Cholasma Signup and view all the answers

Which of the following integument assessment components involves assessing subjective data such as changes in pigmentation or moles?

Subjective data collection Signup and view all the answers

How does skin change due to aging affect a person's risk of temperature regulation?

Decreased gland function results in poor temperature regulation Signup and view all the answers

What characteristic does not typically describe the hair changes seen in aging adults?

Thicker hair strands Signup and view all the answers

What is the primary purpose of documenting subjective and objective data gathered during integument assessment?

To improve clinical decision-making and nursing practice Signup and view all the answers

Which of the following assessments is most relevant for evaluating a newborn's skin condition?

Inspection for cradle cap or milia Signup and view all the answers

What does 'ANO x3' refer to during a neuro check?

Alert and oriented to person, place, and time Signup and view all the answers

Which skin condition is characterized by small white bumps commonly seen in infants?

Milia Signup and view all the answers

What changes in adolescents' skin can be attributed to hormonal fluctuations?

Increased glandular activity Signup and view all the answers

In integument assessment, which of the following findings would be classified as a secondary lesion?

Scar Signup and view all the answers

What is the primary function of the subcutaneous layer in the integumentary system?

Providing insulation and cushioning Signup and view all the answers

Study Notes

Quick Neuro Check

Components: Alertness, orientation to person, place, and time, communication, and motor response.
Alertness: Range from alert to coma.
Orientation: Ability to understand present situation.
Communication: Clear and articulate speech.
Motor Response: Ability to follow commands and move extremities.

Integument Assessment

Purpose: Inspect and palpate skin, nails, and hair to assess overall health.
Skin Covers: 1.68 square meters in the average adult.

Developmental Considerations

Infants: Covered with lanugo hair at birth, which is replaced by fine vellus hair. Vernix caseosa serves as a protective layer. Milia and cradle cap may develop.
Adolescents: Increased secretion from apocrine glands, active sebaceous glands, and increased subcutaneous fat deposits.
Pregnant Persons: Linea nigra, chloasma, and striae gravidarum.
Aging Adults: Decreased elastin, collagen, subcutaneous fat, and muscle tone. Hair becomes thinner and whiter. Nails grow more slowly and have prominent longitudinal ridges.

Subjective Data

History: Previous skin disease, allergies, birthmarks.
Changes: Pigmentation, mole, dryness, moisture, pruritus, bruising, rash or lesions, medications.
Hair and Nails: Hair loss, change in nails, environmental or occupational hazards.
Self-care: Sunscreen use and soap preference.

Objective Data

Assessment: Inspect and palpate skin, hair, and nails. Be aware of external variables and the patient's baseline characteristics.
Hidden Areas: Assess skin folds, incorporating assessment during bathing.

Hair Assessment

Inspect and Palpate: Observe color, texture, distribution, and lesions.
Scalp: Assess for lesions or infestation.

Nail Assessment

Inspect and Palpate: Observe shape, contour, consistency, and color.
Capillary Refill: Assess blood flow by observing the time it takes for color to return.

Skin Assessment

Color: Pallor, erythema, cyanosis, and jaundice.
Temperature: Warm or cool to touch.
Moisture: Dry, moist, or clammy.
Texture: Smooth, rough, thick, or thin.
Edema: Fluid accumulation in the intercellular spaces, graded on a 4-point scale.

Lesions

Abuse or Trauma: Bruising patterns can indicate abuse.
Assessment: Observe color, elevation, pattern, size, location, distribution, and exudate.
Danger Signs: ABCDE (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, Elevation and evolution).

Skin Lesion Configurations

Annular: Circular lesion spreading from the center.
Confluent: Lesions merging together.
Discrete: Distinct and separate lesions.
Grouped: Clustered lesions.
Gyrate: Twisted, coiled, or spiral lesions.
Target: Concentric rings resembling an iris.
Linear: Linear or streak-like lesions.
Polycyclic: Annular lesions growing together.
Zosteriform: Linear arrangement of lesions along a nerve root.

Categories of Lesions

Primary: Develop on previously unaltered skin.
- Macule: Flat, less than 1 cm in diameter.
- Patch: Flat, greater than 1 cm in diameter.
- Papule: Solid, elevated, less than 1 cm in diameter.
- Plaque: Solid, elevated, greater than 1 cm in diameter.
- Nodule: Solid, elevated, greater than 1 cm in diameter, extends deeper into the dermis.
- Tumor: Solid, elevated, larger than 2 cm in diameter.
- Wheal: Superficial, raised, transient.
- Urticaria: Wheals joining together.
- Vesicle: Blister, elevated cavity containing fluid, less than 1 cm in diameter.
- Bulla: Blister, elevated cavity containing fluid, greater than 1 cm in diameter.
- Cyst: Encapsulated fluid-filled cavity.
- Pustule: Cavity filled with pus.
Secondary: Result from changes in primary lesions over time.
Vascular: Caused by blood vessel abnormalities.
- Hemangiomas: Benign proliferation of blood vessels.
  - Port-wine stain: Large, flat macular patch.
  - Strawberry mark: Raised red area with well-defined borders.
  - Cavernous hemangioma: Reddish-blue, irregular, solid, spongey mass of blood vessels.
- Telangiectases: Appearance of blood vessels on the skin's surface.
  - Telangiectasia: Permanently enlarged and dilated blood vessels.
  - Spider or star angioma: Fiery red star-shaped marking with a solid circle center.
  - Venous lake: Blue-purple dilation of smaller blood vessels.
- Purpuric lesions: Caused by blood leaking out of vessels.
  - Petechiae: Tiny hemorrhages, round, discrete.
  - Purpura: Excessive patch of petechiae, greater than 3 mm in size.

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Description

This quiz covers essential components of nursing assessments including neuro checks and integument evaluations. It examines key factors like alertness, orientation, communication, and motor responses, along with developmental considerations across different life stages. Test your knowledge of these critical nursing concepts.