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PN 111 Integumentary And HEENT Exam Questions And Accurate Answers
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PN 111 Integumentary And HEENT Exam Questions AndAccurate Answers
What is jaundice
A yellowing of the skin and eyes
Where does the nurse assess for jaundice
sclera, soles of the hands and bottoms of the feet
What is petechiae?
pin point purplish or red discoloration of an area of the skin.
How does the nurse assess nevus (moles) or lesions for possible skin cancer
(melanoma)
By using the ABCDEF rule---F stands for Familiar
What are the four stages of a pressure ulcer?
◦Stage I = prolonged redness with unbroken skin
◦Stage II = partial-thickness skin loss appears as a superficial abrasion, blister, or
excoriation
◦Stage III = full-thickness skin loss with damage to subcutaneous tissue (may note
serosanguineous drainage)
◦Stage IV = full-thickness skin loss with invasion of deeper tissue into muscle and/or
bone; wound appears as an open ulceration with purulent drainage and peripheral
crusting
***Some are unstageable with tunnels and discoloration
, Impetigo
A highly contagious bacterial infection which is easily passed to others. Impetigo is
caused by staphylococcal or streptococcal pathogens. Very common in children and
crowded living conditions.
§Usually appears as red sores on the face, especially around a child's nose and mouth,
and on hands and feet. The sores burst and develop honey-colored crusts
Why would the nurse need to be careful when turning or repositioning a geriatric
patient?
: Care is taken when repositioning older adults and when using adhesives to the skin
Skin is thinner-thinning means atrophy of skin much easier to tear
What is an ecchymosis?
§Ecchymosis (bruise)-vascular skin lesion--the passage of blood from ruptured blood
vessels into subcutaneous tissue, marked by a purple discoloration of the skin. May
indicate bleeding disorder, trauma, and abuse--especailly if there are multiple bruises in
various stages of healing
What does the mnemonic PERRLA stand for and what does is it used for?
It is used to assess the pupillary response and accommodation of the eyes. This is an
acronym that represents Pupils, Equal, Round, Reactive to Light Accommodation. The
pupillary response is assessed by shining a light in the patient's eye and observing for
direct and indirect constriction (consensual). Accommodation is assessed by holding an
object 10-12 inches in front of the patient and asking them to follow the object while the
nurse moves the object toward the nose.
The pupils should constrict and the eyes converge. The pupils will constrict when an
object is near to the eyes or when the light is plentiful. Conversely, if an object is distant
or there is limited light, the pupils will dilate, or enlarge.
What is cyanosis and what does it indicate?
Cyanosis-physical sign causing bluish discoloration of the skin and mucous membranes.
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