TEST BANK HEALTH
ASSESSMENT IN NURSING (7TH)
BY JANET R WEBER & JANE H
KELLEY CHAPTERS 1-34
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, integumentary system Consists of the skin, mucous membranes, hair, and nails
skin is the largest organ in the body
Physical barrier
Protects our body
Eeythema A common result of inflammation, allergy, and fever
Skin redness & warmth
freckle macule; flat pigment that appear after sun exposure
vitiligo loss of pigment in areas of the skin
Striae stretch marks
Stage 1 pressure ulcer intact skin with nonblanchable redness
stage 2 pressure ulcer Partial thickness loss of dermis presenting as a shallow open ulcer with
red-pink wound bed without slough
stage 3 pressure ulcer full thickness tissue loss with visible fat
stage 4 pressure ulcer Full-thickness tissue loss with exposed bone, muscle, or tendon; slough
or eschar may be present
Unstagable ulcer Full-thickness tissue loss in which the base of the ulcer is covered by
slough
Maculeflat, colored spot on the skin; less than 1cm with circumscribed border
*freckles, flat moles, petechiae
nodule Elevated, solid, palpable mass that extends deeper into dermis; 0.5-2 cm
* keloid, lipoma, squamous cell carcinoma
papule small, solid skin elevation; have circumscribed border less than 0.5 cm
* psoriasis, actinic keratosis
VesiclePalpable mass containing serious fluid. Vesicles are less than 0.5 cm
*pemphigus, contact dermatitis, large burns, Blisters m
wheal raised red skin lesion due to interstitial fluid
*hives, insect bites
pustule pus filled vesicle or bulla.
*acne, impetigo, furuncles
cyst sac containing fluid
Erosion Loss of superficial epidermis that does not extend to the dermis
* canker sore, scratch, stretch mark
ulcer Skin loss extending past epidermis with necrotic tissue loss
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, *pressure ulcer
fissure an opening; a groove; a split; crack in skin
ABCDE of skin cancer asymmetry, border, color, diameter, evolving
basal cell carcinoma (BCC) malignant tumor of the basal layer of the epidermis; the most
common type of skin cancer
Melanoma skin cancer
squamous cell carcinoma (SCC) skin cancer that begins in the epidermis but may grow
into
deeper tissue; does not generally metastasize to other areas of the body
Cranium houses and protects the brain
•frontal (1)
•parietal (2)
•temporal (2)
•occipital (1)
•ethmoid (1)
•sphenoid (1)
face Facial bones give shape to the face (14 bones)
•maxilla (2)
•zygomatic (cheek)(2)
•inferior conchae (2)
• nasal (2)
•lacrimal (2)
•palatine (2)
•vomer (1)
•mandible (jaw)(1)
Nursing the protection, promotion, and optimization of health and abilities, prevention
of illness and injury, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, communities, and populations
Assessment first step of the nursing process; most critical phase; assessment is ongoing and
continuous throughout all phases of the nursing process
*collection of subjective and objective data
Phases of the nursing process Assessment
Diagnosis
Planning
Implementation
Evaluation
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