NSG 316 EXAM 1 QUESTIONS AND ANSWERS
what is skin turgor? - Answers - ability of skin to return to place promptly when released
how and why do we test for skin turgor? - Answers - grasp the skin under or above
collarbone with two fingers. hold for a few seconds and release
measures elasticity. can indicate dehydration or extreme weight loss (extra skin)
normal and abnormal skin turgor - Answers - snaps back rapidly
takes time to return to normal position. called tenting
abnormal nail findings - Answers - - brittle/splitting
- linear pigmentation or striata
- <160 degrees or it is 180 degrees (clubbing or spooning)
normal/expected nail findings - Answers - - angle of 160 degrees or less
- clean (suggests adequate self-care)
- smooth surface
- transluscent/pink nail bed
ABCDE - Answers - often used for skin cancer assessment
- asymmetry, border, color, diameter, elevation
procedure for assessing skin lesions - Answers - - palpation
- adequate lighting
- woodlight/magnifying
- measure length, width, depth
how and why we test for capillary refill - Answers - measure by pressing down on nail
bed for a couple seconds
checks for peripheral circulation or oxygen saturation levels (respiratory)
normal and abnormal capillary refill findings - Answers - - color returns within 1-2
seconds
- takes longer than 1-2 seconds
2+ edema - Answers - moderate pitting
indentation subsides rapidly
1+ edema - Answers - mild pitting
, slight indentation
no perceptible swelling of the leg
3+ edema - Answers - deep pitting
looks swollen
indentation remains for short time
4+ edema - Answers - very deep pitting
leg is very swollen
indentation lasts long time (can be indefinite)
ecchymosis (bruise) - Answers - - any type of injury that causes blood vessels to burst
open
- leaking blood under the skin
purpura - Answers - - dark, red discolored areas due to decreased vascularity of the
skin but increased vascular fragility
petechiae - Answers - round spots that appear on skin as a result of bleeding
red, brown, or purple
secondary lesions - Answers - resulting from a change in primary lesion from passage
of time (evolutionary)
primary lesions - Answers - develop on previously unaltered skin
- macules, papules, nodule, tumor, cyst, papule, vesicle, etc.
stage I pressure ulcer - Answers - intact skin (red but unbroken)
skin does not blanch
brown-tan - Answers - - can be normal for different ethnicities
- due to Addisons disease (dec cortisol) stimulates increased melanin production
- bronzed appearance
- most apparent in perineum/pressure points
jaundice - Answers - yellowish skin color indicating increased amounts of bilirubin in
blood
erythema - Answers - intense redness from the skin
differs from rubor based on severity
cyanosis - Answers - bluish mottled color from decreased perfusion (hypoxia)
pallor - Answers - unhealthy pale appearance, vasoconstriction
hirsutism - Answers - shaggy or excessive hair
what is skin turgor? - Answers - ability of skin to return to place promptly when released
how and why do we test for skin turgor? - Answers - grasp the skin under or above
collarbone with two fingers. hold for a few seconds and release
measures elasticity. can indicate dehydration or extreme weight loss (extra skin)
normal and abnormal skin turgor - Answers - snaps back rapidly
takes time to return to normal position. called tenting
abnormal nail findings - Answers - - brittle/splitting
- linear pigmentation or striata
- <160 degrees or it is 180 degrees (clubbing or spooning)
normal/expected nail findings - Answers - - angle of 160 degrees or less
- clean (suggests adequate self-care)
- smooth surface
- transluscent/pink nail bed
ABCDE - Answers - often used for skin cancer assessment
- asymmetry, border, color, diameter, elevation
procedure for assessing skin lesions - Answers - - palpation
- adequate lighting
- woodlight/magnifying
- measure length, width, depth
how and why we test for capillary refill - Answers - measure by pressing down on nail
bed for a couple seconds
checks for peripheral circulation or oxygen saturation levels (respiratory)
normal and abnormal capillary refill findings - Answers - - color returns within 1-2
seconds
- takes longer than 1-2 seconds
2+ edema - Answers - moderate pitting
indentation subsides rapidly
1+ edema - Answers - mild pitting
, slight indentation
no perceptible swelling of the leg
3+ edema - Answers - deep pitting
looks swollen
indentation remains for short time
4+ edema - Answers - very deep pitting
leg is very swollen
indentation lasts long time (can be indefinite)
ecchymosis (bruise) - Answers - - any type of injury that causes blood vessels to burst
open
- leaking blood under the skin
purpura - Answers - - dark, red discolored areas due to decreased vascularity of the
skin but increased vascular fragility
petechiae - Answers - round spots that appear on skin as a result of bleeding
red, brown, or purple
secondary lesions - Answers - resulting from a change in primary lesion from passage
of time (evolutionary)
primary lesions - Answers - develop on previously unaltered skin
- macules, papules, nodule, tumor, cyst, papule, vesicle, etc.
stage I pressure ulcer - Answers - intact skin (red but unbroken)
skin does not blanch
brown-tan - Answers - - can be normal for different ethnicities
- due to Addisons disease (dec cortisol) stimulates increased melanin production
- bronzed appearance
- most apparent in perineum/pressure points
jaundice - Answers - yellowish skin color indicating increased amounts of bilirubin in
blood
erythema - Answers - intense redness from the skin
differs from rubor based on severity
cyanosis - Answers - bluish mottled color from decreased perfusion (hypoxia)
pallor - Answers - unhealthy pale appearance, vasoconstriction
hirsutism - Answers - shaggy or excessive hair
