Exam (elaborations)
NUR 216 /NUR 216- Module 4 EXAM
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NUR 216 /NUR 216- Module 4 EXAM
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NUR 216 /NUR 216- Module 4 EXAMList five things you need to do prior to beginning the assessment. - ANSWER-1. Review
the client chart
2. Gather needed supplies
3. Announces presence to client
4. Ensures client privacy
5. Performs hand hygiene
What techniques are used for a skin assessment? - ANSWER-Inspection and palpation
What do you inspect during a skin assessment? - ANSWER-Color, texture, moisture,
and integrity
What do you palpate for during a skin assessment? - ANSWER-Texture, moisture
temperature, mobility, and turgor
What tools are needed in preparation for a skin assessment? - ANSWER-Strong direct
lighting, gloves, penlight, and small centimeter ruler.
Epidermis - ANSWER-The surface layer is a combination of dead cells on the outside
and live cells on the inside. It takes about a month for cells to move from the inner
surface to the outer surface. This is a way the skin constantly renews itself.
Dermis - ANSWER-The middle layer is composed of connective tissue that is formed by
a dense combination of interconnecting collagen and elastic fibers. It contains blood
vessels, hair follicles, cutaneous nerve endings, sensory receptors, lymphatics, ans
sebaceous and sweat glands.
Subcutaneous - ANSWER-The innermost layer contains fatty tissue. This layer stores
fat for energy and provides insulation for even temperature control. It has a soft
cushioning effect that protects the body and gives the skin flexibility over the skeleton
beneath.
List the functions of skin and nails. - ANSWER--Protect the inner body parts and organs
-Body temperature regulation through shivering and sweating
-Sensory perception of temperature, touch, and pain
-Excrete waste and toxic substances
-Produce vitamin D
Elasticity in the older adult. - ANSWER--Loses elasticity; skin folds and sags.
-Decreased skin turgor.
Sweat and Sebaceous glands in the older adult. - ANSWER-Decrease in number and
function, leaving skin dry.
, Senile Purpura in the older adult. - ANSWER-Discoloration due to increasing capillary
fragility.
Skin breakdown due to multiple factors in the older adult. - ANSWER-Cell replacement
is slower and wound healing is delayed.
Hair matrix in the older adult. - ANSWER-Functioning melanocytes decrease, leading to
gray fine hair.
Most important environmental risk factor for skin cancer. - ANSWER-Exposure to
ultraviolet (UV) radiation both from sun and tanning sources.
What are questions you can ask to gather subjective data health history questions? -
ANSWER--Past history of skin disease, allergies, hives, psoriasis, or eczema?
-Change in pigmentation or color, size, shape, tenderness?
-Excessive dryness or moisture?
-Pruritus or skin itching?
-Excessive bruising?
-Rash or lesions?
-Medications: prescription and over-the-counter?
-Hair loss?
-Change in nails' shape, color, or brittleness?
-Environmental or occupational hazards?
-Self-care behaviors?
What are questions you can ask aging adults to gather subjective data health history
questions? - ANSWER--What changes have you noticed in your skin in past few years?
-Any delay in wound healing?
-Any change in feet: toenails, bunions, wearing shoes?
-Falling: bruises, trauma?
-History of diabetes or peripheral vascular disease?
Melanoma in Whites is noted to be ___ times higher than in Blacks and ___ times
higher than in Hispanics. - ANSWER-20
4
List four skin conditions that are noted to be specific to Black patients. - ANSWER--
Keloids
-Pigmentary disorders
-Pseudofolliculitis
-Melasma
List variables that influence skin color. - ANSWER--Emotional states
-Temperature
-Cigarette smoking
-Prolonged elevation/dependent position of extremities
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