NUR1060 EXAM 2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
What is the purpose of assessing the skin?
To evaluate the overall health of the patient. The skin assessment should be carried out every time they
are identified as high risk following an assessment or reassessment of pressure ulcer risk.
What is normal skin?
Skin in warm, dry, and skin turgor less than 2 seconds, no abnormal pigmentation, bleeding, rash or
other lesions. The patient is negative for edema in the upper and lower extremities, and face.
How do you assess for tugor?
Grasp the skin between 2 fingers so that it is tented up. Commonly below the clavicle, on the forearm,
and abdomen. Skin with normal turgor snaps rapidly back to its normal position. Less than 2 seconds.
What does abnormal skin turgor mean?
If the skin remains tented for 3 seconds or more this can be a sign of dehydration.
What is the purpose of assessing the nails?
Fingernails and toenails say a lot about the patient, I need to inspect and palpate them whenever I
assess the skin. Significant irregularities in color, shape, and structure may point to underlying problems
or previous trauma or infection.
What are normal nails?
, Nails are translucent, shiny and firm in texture.
What are abnormal nails?
Ripples on nails, pitted nails, or nail clubbing
Ripples or pitted nails signify what?
Skin disorder, Psoriasis, Eczema or arthritis
Nail clubbing signify what?
Heart Disease, Lung Disease, Liver Disease, Thyroid Disease, Inflammatory Bowel Disease, and HIV/AIDS
What does ABCDE stand for?
Asymmetry, Border, Color, Diameter, Evolve (changing)
What are the methods for assessing the Thorax/Lungs?
I will be using Inspection, Auscultation, Percussion, and Palpation.
What are the anatomical landmarks?
Suprasternal notch, Manubrium, Sternum, Intercoastal spaces.
What are the vertical lines?
Midsternal, Midclavicular, Clavicle, Mid/Anterior/Posterior Axillary, Midscapular, Spinal column.
What are you looking for when assessing the anterior/posterior diameter?
Normal anterior/posterior 2:1 ratio. Abnormal findings may indicate barrel chest.
What would you INSPECT when looking at your patient's chest?
Skin color and condition, inspecting for structural abnormalities, and breathing pattern.
COMPLETE SOLUTIONS VERIFIED
What is the purpose of assessing the skin?
To evaluate the overall health of the patient. The skin assessment should be carried out every time they
are identified as high risk following an assessment or reassessment of pressure ulcer risk.
What is normal skin?
Skin in warm, dry, and skin turgor less than 2 seconds, no abnormal pigmentation, bleeding, rash or
other lesions. The patient is negative for edema in the upper and lower extremities, and face.
How do you assess for tugor?
Grasp the skin between 2 fingers so that it is tented up. Commonly below the clavicle, on the forearm,
and abdomen. Skin with normal turgor snaps rapidly back to its normal position. Less than 2 seconds.
What does abnormal skin turgor mean?
If the skin remains tented for 3 seconds or more this can be a sign of dehydration.
What is the purpose of assessing the nails?
Fingernails and toenails say a lot about the patient, I need to inspect and palpate them whenever I
assess the skin. Significant irregularities in color, shape, and structure may point to underlying problems
or previous trauma or infection.
What are normal nails?
, Nails are translucent, shiny and firm in texture.
What are abnormal nails?
Ripples on nails, pitted nails, or nail clubbing
Ripples or pitted nails signify what?
Skin disorder, Psoriasis, Eczema or arthritis
Nail clubbing signify what?
Heart Disease, Lung Disease, Liver Disease, Thyroid Disease, Inflammatory Bowel Disease, and HIV/AIDS
What does ABCDE stand for?
Asymmetry, Border, Color, Diameter, Evolve (changing)
What are the methods for assessing the Thorax/Lungs?
I will be using Inspection, Auscultation, Percussion, and Palpation.
What are the anatomical landmarks?
Suprasternal notch, Manubrium, Sternum, Intercoastal spaces.
What are the vertical lines?
Midsternal, Midclavicular, Clavicle, Mid/Anterior/Posterior Axillary, Midscapular, Spinal column.
What are you looking for when assessing the anterior/posterior diameter?
Normal anterior/posterior 2:1 ratio. Abnormal findings may indicate barrel chest.
What would you INSPECT when looking at your patient's chest?
Skin color and condition, inspecting for structural abnormalities, and breathing pattern.
