Lesions
Superficial, non-palpable lesions that are less than 1cm.
What is macule?
Patch: greater than 1cm
A bluish skin discoloration caused by unsaturated hemoglobin.
What is cyanosis?
The nurse is assessing a patient whose skin is wet with noticable beads of sweat on the face and chest. The nurse would document this as:
What is diaphoresis?
The apical heart rate must be asucultated for how long.
What is 1 full minute OR 60 seconds.
The function of this part of the integumentary system includes protecting fingertips and assisting in fine motor skills.
What are finger nails.
A form of skin cancer mainly assocated with sun exposure, presenting as a pearly flesh color.
What is basal cell carcinoma?
This term describes an abnormal redness of the skin due to increased blood flow.
What is erythema?
The nurse is caring for a patient with a rash limited to the right forearm after coming into contact with poison oak leaves. The nurse would document the rash configuration as:
What is localized OR regional.
A heart rate below 60 beats per minute is known as this condition.
What is bradycardia?
Patients with difficulty breathing often assume this position to improve airflow.
What is tripod positioning?
The nurse is caring for a client who was stung by a bee and is exhibiting a superificial, raised lesion that is temporary. The nurse would document this as a(an):
A yellowish skin tone, often associated with liver disease.
What is jaundice?
The nurse notes a wound on the patient's left heel that appears like a popped blister. The nurse would document this as which stage for pressure ulcers?
What is stage 2?
2 examples of core temperature locations.
What are rectal OR temporal OR esophageal OR urethra/bladder?
The skin helps regulate body temperature, provides sensory perception, and produces this essential vitamin.
What is Vitamin D?
The nurse is caring for a patient with sunburn who is experiencing very large, serous fluid filled blisters that are 4 cm in diameter. these are known as:
Bullae (blisters greater than 1cm)
vescicles: less than 1cm
This term describes pale skin, which may indicate anemia or poor circulation.
What is pallor?
The nurse is performing an assessment and notes the finger nails curve downward and the angle exceeds 180 degrees. The nurse would document this as:
What is clubbing present?
Name two factors that can cause an inaccurate pulse oximetry reading.
What are nail polish OR poor circulation OR cold extremities OR inflated blood pressure cuff/tourinquet OR poor perfusion OR hypotension OR peripheral artery disease.
A way to assess hydration status when assessing the skin other than visualizng mucous membranes is:
What is skin turgor OR tenting?
These vascular lesions can be associated with potential clotting disorders.
what are petechiae and purpura?
Petechiae: less than 0.5 cm
Purpura: greater than 0.5 cm
The skin condition associated with rapid infusion of Vancomycin resulting in bright red skin.
What is red man syndrome OR Vancomycin flushing syndrome.
The nurse notes abrupt lines and transverse ridges in the client's nails. The client reports a significant hospital admission for sepsis and organ failure several months prior. The nurse would document these ridges as:
what are beau lines.
A client presents with a respiratory rate of 28, a pulse ox of 99% on room air, and use of accessory muscles. The patient's skin is cherry red in color.
The nurse suspects what kind of poisoning?
What is carbon monoxide poisoning?
The pressure in the arteries when the heart contracts is known as this vital sign.
What is SYSTOLIC blood pressure?