NUR 325 EXAM 2 QUESTIONS AND ANSWERS
1) Why is a skin assessment important? What general information about the body as a
whole is obtained through a skin assessment? Know important issues to ask when
taking a history about the skin. - Answers :- You can gather clues about health problems
through the skin.
- Information about body's circulation, nutrition & signs of systemic disease.
- Past history of skin disease, change in pigmentation/color, change in mole
size/shape/color/exnderness, dryness/moisture, pruritus, bruising, rash/lesion, hair loss,
change in nails, etc & Rx medications
Pallor - Answers :- Extreme or unusual paleness; skin takes color of connective tissue
(collagen); common in anxiety or fear.
- Observe in mucous membranes, lips & nail beds
Erythema - Answers :- Intense redness from excess blood from dilated superficial
capillaries
- Expected with fever, local inflammation or emotional reactions in vascular flush areas
Cyanosis - Answers :- Bluish discoloration of the skin resulting from poor circulation or
inadequate oxygenation of the blood.
- Best seen in lips, nose, cheeks, ears & oral mucous membranes.
- Most conditions causing this also cause decreased oxygenation of the brain
Jaundice - Answers :- Yellowing of skin; indicates rising amounts of bilirubin in blood.
- First noted in junction of hard & soft palates in mouth and in sclera of eye
Technique used to effectively assess skin temperature: - Answers :use backs of hand to
palpate person; skin should be warm and temperature should be bilaterally equal
Diaphoresis - Answers :- profuse sweating (perspiration) - accompanies increased
metabolic rate
- can indicate anxiety, pain or low BP
Dehydration - Answers :- A serious reduction in the body's water content
- dry mucous membranes, lips, decreased skin turgor
How to assess for skin turgor - Answers :- Infants: test mobility of skin over abdomen
- Adults: punch a large fold of skin on anterior of chest under clavicle
- Can be affected by dehydration, extreme weight loss and age
Why is an infant more susceptible to dehydration? - Answers :- Higher body water
content along with higher metabolic rates
- They require greater volumes of water to maintain fluid equilibrium
- Skin is thin, smooth & elastic therefor much more permeable than an adult's
,Papule - Answers :- small (less than 1 cm in diameter), solid, raised lesion on surface of
the skin
- something you can feel
- caused by superficial thickening of dermis
ex: mole, wart
Nodule - Answers :- solid, round or oval elevated lesion 1 cm or more in diameter
- may extend deeper into dermis than papule
Tumor - Answers :- larger than a few centimeters in diameter
-firm or soft
- deeper into dermis; may be benign or malignant
Wheal - Answers :- superficial, raised, transient, and erythematous
- slightly irregular shape from edema
Pustule - Answers :raised spot on the skin containing pus
Danger sign of lesions - Answers :- Asymmetry: not regularly round or oval
- Border Irregularity: ragged edges
- Color variation: areas of brown, tan, black, blue, red or combination
- Diameter: greater than 6 mm
- Elevation/enlargement
Skin developmental considerations: Infant - Answers :newborns with brown/black skin
have lighter skin tone than parents because of immature pigment formation; full
melantonic color event in nail beds & scrotal folds
Skin developmental considerations: Adolescence - Answers :- increased sebaceous
gland activity which creates oiliness and acne
- acne lesions may appear as early as 7-8 years and peak at 14-17 in girls and 16-19 in
boys.
- facial hair appears on boys first on lip, then cheeks and below lip, last on chin
- noticeable enlargement of thyroid cartilage causing deeper voice
Skin developmental considerations: Pregnant women - Answers :- striae appear during
2nd trimester on abdomen, breasts and sometimes thighs
- vascular "spiders" are common because of increased estrogen
- thyroid gland enlarges slightly because of hyperplasia of tissue & increased vascularity
Skin developmental considerations: Elderly - Answers :-senile lentigines (liverspots):
clusters of melanocytes appearing after extensive sun exposure on forearms & back of
hand
- more prominent facial bones & orbits
- sagging facial skin as a result of decreased elasticity
- decreased subcutaneous fat & moisture in skin
, Mongolian spot - Answers :- common variation of hyperpigmentation in newborns Black
(90%), Asian (80%), American Indian (80%)
- blue/black to purple area at sacrum, buttocks and sometimes abdomen, thighs,
shoulders or arms due to deep dermal melanocytes
- gradually fades in first year, frequently still lightly visible in adulthood
Stork bite (salmon patch) - Answers :- nevus simplex
- flat, irregularly shaped red/pink patch found on forehead, eyelid or upper lip but most
commonly at back of neck
- usually fades in first year
Linea nigra - Answers :dark line of pigmentation from the umbilicus extending to the
pubic area
Striae - Answers :(lineae albicantes) silvery white or pink scar tissue formed by
stretching of abdominal, breast and sometimes thigh skin with pregnancy (2nd
trimester) or obesity
Capillary refill test - Answers :- Pressure is applied to the nail bed until it turns white
(called blanching) and once the tissue has blanched, pressure is removed while the
patient holds their hand above their heart. Return of blood is indicated by the nail
turning back to a pink color.
- healthy return is 1-2 seconds
- indicates status of peripheral circulation
Normal shape and contour of nails - Answers :- surface is slightly curved or flat;
posterior & lateral folds are smooth and rounded
- 160 degrees
- firm to palpation
Clubbing - Answers :- occurs with congenital heart disease and neoplastic & pulmonary
diseases which cause release of growth factors & promote vessel growth
- angle straightens out to 180 degrees, nail base feels spongy
- can reverse if primary disease is treated
Pruritus - Answers :itching; most common skin symptom.
- occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, lice etc
Diaper rash - Answers :- diaper dermatitis
- red, moist maculopapular patch with poorly defined borders in diaper area extending
along inguinal & gluteal folds
- infrequent diaper changes or occlusive coverings
- inflammatory diseased caused by skin irritation from ammonia, heat, moisture &
occlusive diapers
1) Why is a skin assessment important? What general information about the body as a
whole is obtained through a skin assessment? Know important issues to ask when
taking a history about the skin. - Answers :- You can gather clues about health problems
through the skin.
- Information about body's circulation, nutrition & signs of systemic disease.
- Past history of skin disease, change in pigmentation/color, change in mole
size/shape/color/exnderness, dryness/moisture, pruritus, bruising, rash/lesion, hair loss,
change in nails, etc & Rx medications
Pallor - Answers :- Extreme or unusual paleness; skin takes color of connective tissue
(collagen); common in anxiety or fear.
- Observe in mucous membranes, lips & nail beds
Erythema - Answers :- Intense redness from excess blood from dilated superficial
capillaries
- Expected with fever, local inflammation or emotional reactions in vascular flush areas
Cyanosis - Answers :- Bluish discoloration of the skin resulting from poor circulation or
inadequate oxygenation of the blood.
- Best seen in lips, nose, cheeks, ears & oral mucous membranes.
- Most conditions causing this also cause decreased oxygenation of the brain
Jaundice - Answers :- Yellowing of skin; indicates rising amounts of bilirubin in blood.
- First noted in junction of hard & soft palates in mouth and in sclera of eye
Technique used to effectively assess skin temperature: - Answers :use backs of hand to
palpate person; skin should be warm and temperature should be bilaterally equal
Diaphoresis - Answers :- profuse sweating (perspiration) - accompanies increased
metabolic rate
- can indicate anxiety, pain or low BP
Dehydration - Answers :- A serious reduction in the body's water content
- dry mucous membranes, lips, decreased skin turgor
How to assess for skin turgor - Answers :- Infants: test mobility of skin over abdomen
- Adults: punch a large fold of skin on anterior of chest under clavicle
- Can be affected by dehydration, extreme weight loss and age
Why is an infant more susceptible to dehydration? - Answers :- Higher body water
content along with higher metabolic rates
- They require greater volumes of water to maintain fluid equilibrium
- Skin is thin, smooth & elastic therefor much more permeable than an adult's
,Papule - Answers :- small (less than 1 cm in diameter), solid, raised lesion on surface of
the skin
- something you can feel
- caused by superficial thickening of dermis
ex: mole, wart
Nodule - Answers :- solid, round or oval elevated lesion 1 cm or more in diameter
- may extend deeper into dermis than papule
Tumor - Answers :- larger than a few centimeters in diameter
-firm or soft
- deeper into dermis; may be benign or malignant
Wheal - Answers :- superficial, raised, transient, and erythematous
- slightly irregular shape from edema
Pustule - Answers :raised spot on the skin containing pus
Danger sign of lesions - Answers :- Asymmetry: not regularly round or oval
- Border Irregularity: ragged edges
- Color variation: areas of brown, tan, black, blue, red or combination
- Diameter: greater than 6 mm
- Elevation/enlargement
Skin developmental considerations: Infant - Answers :newborns with brown/black skin
have lighter skin tone than parents because of immature pigment formation; full
melantonic color event in nail beds & scrotal folds
Skin developmental considerations: Adolescence - Answers :- increased sebaceous
gland activity which creates oiliness and acne
- acne lesions may appear as early as 7-8 years and peak at 14-17 in girls and 16-19 in
boys.
- facial hair appears on boys first on lip, then cheeks and below lip, last on chin
- noticeable enlargement of thyroid cartilage causing deeper voice
Skin developmental considerations: Pregnant women - Answers :- striae appear during
2nd trimester on abdomen, breasts and sometimes thighs
- vascular "spiders" are common because of increased estrogen
- thyroid gland enlarges slightly because of hyperplasia of tissue & increased vascularity
Skin developmental considerations: Elderly - Answers :-senile lentigines (liverspots):
clusters of melanocytes appearing after extensive sun exposure on forearms & back of
hand
- more prominent facial bones & orbits
- sagging facial skin as a result of decreased elasticity
- decreased subcutaneous fat & moisture in skin
, Mongolian spot - Answers :- common variation of hyperpigmentation in newborns Black
(90%), Asian (80%), American Indian (80%)
- blue/black to purple area at sacrum, buttocks and sometimes abdomen, thighs,
shoulders or arms due to deep dermal melanocytes
- gradually fades in first year, frequently still lightly visible in adulthood
Stork bite (salmon patch) - Answers :- nevus simplex
- flat, irregularly shaped red/pink patch found on forehead, eyelid or upper lip but most
commonly at back of neck
- usually fades in first year
Linea nigra - Answers :dark line of pigmentation from the umbilicus extending to the
pubic area
Striae - Answers :(lineae albicantes) silvery white or pink scar tissue formed by
stretching of abdominal, breast and sometimes thigh skin with pregnancy (2nd
trimester) or obesity
Capillary refill test - Answers :- Pressure is applied to the nail bed until it turns white
(called blanching) and once the tissue has blanched, pressure is removed while the
patient holds their hand above their heart. Return of blood is indicated by the nail
turning back to a pink color.
- healthy return is 1-2 seconds
- indicates status of peripheral circulation
Normal shape and contour of nails - Answers :- surface is slightly curved or flat;
posterior & lateral folds are smooth and rounded
- 160 degrees
- firm to palpation
Clubbing - Answers :- occurs with congenital heart disease and neoplastic & pulmonary
diseases which cause release of growth factors & promote vessel growth
- angle straightens out to 180 degrees, nail base feels spongy
- can reverse if primary disease is treated
Pruritus - Answers :itching; most common skin symptom.
- occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, lice etc
Diaper rash - Answers :- diaper dermatitis
- red, moist maculopapular patch with poorly defined borders in diaper area extending
along inguinal & gluteal folds
- infrequent diaper changes or occlusive coverings
- inflammatory diseased caused by skin irritation from ammonia, heat, moisture &
occlusive diapers
