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NUR 216 Module 4 EXAM 2024 100% CORRECT AZC HEALTH ASSESSMENT
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NUR 216 Module 4 EXAM 2024 100% CORRECT AZC HEALTH ASSESSMENT
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NUR 216 Module 4 EXAM 2024 100% CORRECT AZCHEALTH ASSESSMENT
integumentary system consists of - ANSWER skin, hair, nails
What is the body's largest organ? - ANSWER skin
what are the skin's two layers? - ANSWER epidermis and dermis
Epidermis - ANSWER outer highly differentiated layer
Basal cell layer forms... - ANSWER new skin cells
Dermis - ANSWER inner supportive layer
Dermis consists of... - ANSWER connective tissue or collagen
Beneath the Epidermis and Dermis is - ANSWER subcutaneous layer of adipose
tissue
Skin is... - ANSWER waterproof, protective, and adaptive
integumentary system assessment techniques - ANSWER inspection and
palpation
inspection - ANSWER visual examination
Palpation - ANSWER to examine by touch
Inspection and Palpation: skin color expected findings: - ANSWER General
pigmentation should be even and consistent
Appropriate for ethnicity
Skin exposed to the sun have increased pigmentation
Hyperpigmentation
Hypopigmentation
Hyperpigmentation - ANSWER birthmarks, sun damage, freckles, tan lines
Hypopigmentation - ANSWER scars, stretch marks, vitiligo
Inspection and Palpation: skin color unexpected findings: - ANSWER Pallor,
Erythema, Cyanosis, Jaundice
Pallor - ANSWER paleness. face, conjunctivae, lips, buccal mucosa
, Erythema - ANSWER redness of the skin. Face, skin, pressure sore areas
Erythema causes - ANSWER inflammation/infection, vasodilation, sun exposure,
rash
Cyanosis - ANSWER bluish discoloration of the skin. BEST place to note in darker
skin tones: mucous membranes (conjunctivae, oral mucous membranes, lips) and
nail beds
Cyanosis causes - ANSWER Hypoxia or impaired venous return
Jaundice - ANSWER yellowing of the skin, sclera, mucous membranes
Jaundice causes - ANSWER liver dysfunction, RBC issues
How do you assess skin temperature? - ANSWER Use the backs (dorsal) of your
hands & palpate bilaterally.
Expected findings for skin temperature - ANSWER The skin should be warm with
equal temperature bilaterally.
Expected variations in skin temperature - ANSWER hands and feet may be slightly
cooler in a cold environment
Unexpected findings for skin temperature - ANSWER hyperthermia or hypothermia
What is an expected finding for skin moisture? - ANSWER Dry
What is an unexpected finding for skin moisture? - ANSWER Diaphoretic
What does Diaphoretic mean? - ANSWER excessive sweat
What is an expected finding for skin texture? - ANSWER Smooth
What is an expected variation for skin texture? - ANSWER acne; wrinkles; scars
What is an unexpected finding for skin texture? - ANSWER velvety skin (thyroid
disease); roughness, dryness (xerosis), flakiness (dehydration)
What is an expected finding for skin turgor? - ANSWER recoils immediately
What is an unexpected finding for skin turgor? - ANSWER tenting or edema
What are some causes of decreased turgor or tenting? - ANSWER dehydration or
normal aging
What is edema? - ANSWER accumulation of excess fluid in a tissue
Edema appearance - ANSWER skin appears shiny and tight
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