NUR 216 MODULE 4-5 KEY POINTS ANSWERS .
What causes clubbing? What does it look like? Answer:
It is caused by chronic low oxygen saturation related to heart and lung disease. The angle of the nail can eventually exceed 180 degrees.
What findings would lead a nurse to suspect abuse? Answer: ...
NUR 216 MODULE 4-5 KEY POINTS ANSWERS
2024-2025.
What causes clubbing? What does it look like? Answer:
It is caused by chronic low oxygen saturation related to heart and lung disease. The angle of
the nail can eventually exceed 180 degrees.
What findings would lead a nurse to suspect abuse? Answer:
Bruises at multiple stages of healing, bruises in outline of a hand, belt, or entire object.
What areas are at highest risk for pressure related skin breakdown? Answer: Bo
What categories are assessed in the Braden Scale? Answer:
sensory perception, moisture, activity, mobility, nutrition, and friction or shear.
What assessment findings would indicate dehydration? Answer: Poor turgor such as
tenting. Roughness, dryness, flakiness.
Who should perform foot care on a diabetic? Answer: Podiatrist
What are age-related changes associated with the integumentary system? Answer:
-Skin thin and translucent, drier, tears easily, loss of elasticity and increased wrinkling;
leathery appearance.
-Thinning of hair, hair loss on the scalp or pubic area.
-Slow growth of nails with thickening.
-Decline in glandular structure and function (less oil, moisture, sweat).
-Uneven pigmentation.
-Slow wound healing.
-Little subcutaneous tissue over bony prominences.
-Increased presence of vitiligo, possibly from autoimmune changes.
, What should a diabetic patient be educated on regarding foot care? Answer: The
importance of inspecting the feet daily
Ways to protect the feet (e.g., by wearing shoes when out of bed) Potential complications
involving the feet
Management of symptoms
When to seek advice from a healthcare professional
What to include in the foot care regimen (apply moisturizing lotion on tops and bottoms of
feet but not between toes)—and what not to do (cut corns and calluses, use topical corn
removers, or soak the feet)
What are the functions of the skin? Answer: Body’s first line of defense
Protects against trauma
Protects against ultraviolet radiation
Supports nerve tissue, blood vessels, sweat and sebum glands, and hair follicles
Helps maintain body temperature
Helps maintain fluid balance
Provides sensation with external environment
Involved in absorption and excretion
Involved with immunity
Synthesizes vitamin D
What assessment findings would a nurse expect with a patient with liver failure? Answer:
Pale mucous membranes
Presence of pruritus Presence of petechiae
What patients are at an increased risk for developing a pressure ulcer? Answer:
Patients with poor circulation, such as those with diabetes, atherosclerosis, or low blood
pressure
Patients with reduced oxygen supply in the blood, such as those who use tobacco or are
anemic
Patients with limited mobility or reduced sensation to feel pressure points:
→ nerve damage
→ head injury, stroke, spinal cord injury
→ diabetes
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