Mod 4 Hair, Skin & Nails
This assessment technique uses the eyes to observe the skin for abnormalities.
What is inspection?
White patches in the mouth that cannot be easily removed may indicate this fungal infection.
What is oral candidiasis (thrush)?
The two "R's" in PERRLA stand for these characteristics of the pupils.
What are Round and Reactive?
During a respiratory assessment, the nurse hears a high-pitched, musical sound primarily during expiration that is often associated with narrowed airways.
What is wheezing?
This part of the nursing assessment is completed upon first meeting the patient and includes observations of appearance, behavior, level of consciousness, mobility, and signs of distress.
What is the general survey?
During a skin assessment, the nurse notes intact skin with redness over the sacrum that does not turn white when pressure is applied. This finding indicates this stage of pressure injury.
What is stage 1?
This cranial nerve is assessed by asking the patient to smile, frown, puff out their cheeks, and raise their eyebrows.
What is the Facial Nerve (Cranial Nerve VII)?
This cranial nerve is primarily responsible for hearing.
What is the Vestibulocochlear Nerve (CN VIII)?
These normal breath sounds are heard over most peripheral lung fields and are characterized as soft and low-pitched, with a longer expiratory phase than inspiratory phase.
What are vesicular breath sounds?
A respiratory rate of 32 breaths per minute is an example of this abnormal vital sign.
What is tachypnea?
During a skin assessment, the nurse evaluates this by gently pinches the skin on the clavicle and observing how quickly it returns to its normal position.
What is skin turgor?
These two sinuses are commonly palpated during a routine head and face assessment.
What are the frontal and maxillary sinuses?
When assessing PERRLA, shining a light into one pupil should normally cause both pupils to do this.
What is constrict?
During auscultation, the nurse hears crackling or popping sounds that are often associated with fluid in the alveoli and conditions such as heart failure or pneumonia.
What are crackles (rales)?
Pain that is described as "pins & needles" is an example of this type of pain.
What is neuropathic pain?
During a nail assessment, if a nurse presses on the nail bed and observes how quickly color returns, he/she is performing this test.
What is capillary refill?
This cranial nerve controls tongue movement and is assessed by asking the patient to stick out their tongue.
What is the Hypoglossal Nerve (CN XII)?
Clear, watery drainage from the ear following trauma may indicate leakage of this fluid.
What is cerebrospinal fluid (CSF)?
This breathing pattern is characterized by deep, rapid respirations and is commonly seen in patients with diabetic ketoacidosis as the body attempts to compensate for metabolic acidosis.
What are Kussmaul's respirations?
This anthropometric measurement is used to assess skeletal muscle mass.
What is mid-upper arm circumference?
This nail finding, characterized by an angle greater than 180 degrees between the nail and nail bed, may be associated with chronic hypoxia.
What is clubbing?
This endocrine disorder is characterized by excessive cortisol levels and may present with a moon face, buffalo hump, truncal obesity, and purple striae.
What is Cushing syndrome?
During an eye assessment, a yellow discoloration of this structure may indicate liver dysfunction or jaundice.
What is the sclera?
This breathing pattern consists of alternating periods of apnea and gradually increasing then decreasing respirations.
What is Cheyne-Stokes respiration?
This diagnostic test is used to assess for acute protein deficiency?
What is prealbumin?