exam 2 nursing skills

What are the signs and symptoms of fluid overload?

Increased Vital Signs: Elevated blood pressure and a bounding pulse.

• Weight Gain: Rapid, unexplained weight gain over 1-2 days.

• Congestion: Crackles heard in the lungs and shortness of breath.

• Edema: Swelling in the ankles, legs, and hands (peripheral edema).

What are the signs and symptoms of fluid underload (dehydration)?

• Decreased Vital Signs: Low blood pressure (hypotension) and a rapid, weak pulse.

• Poor Skin Turgor: Skin "tents" when pinched.

• Dry Mucous Membranes: Dry mouth and tongue.

• Dizziness and lightheadedness.

How do you accurately measure fluid balance in adults and infants?

By obtaining daily weights. Weigh the client at the same time each day, on the same scale, and in similar clothing. A change of 1 kg (2.2 lbs) is equivalent to a gain or loss of 1 liter of fluid.

What are the signs of malnutrition in skin, hair, and nails?

• Skin: Dry, flaky, and slow to heal.

• Hair: Dull, brittle, and may fall out easily.

• Nails: Brittle, ridged, or spoon-shaped.

Where do you assess for cyanosis, and what does it look like?

Assess in areas with less pigmentation, such as the oral mucosa, nail beds, and conjunctiva. Cyanosis is a bluish discoloration of the skin, indicating a lack of oxygen in the blood.

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What is the normal vs. abnormal nail base angle?

• Normal: The angle between the nail plate and the nail base is 160 degrees.

• Abnormal: Clubbing is when the angle is 180 degrees or greater, often a sign of chronic hypoxia

How do you assess capillary refill, and what are the normal vs. abnormal findings?

Press on the nail bed until it turns white, then release.

• Normal: Color returns in less than 3 seconds.

• Abnormal: Color returns in more than 3 seconds, indicating poor perfusion.

How do you measure skin turgor, and what does it mean?

Gently pinch the skin over the clavicle or on the back of the hand. Good turgor means the skin immediately returns to place, indicating adequate hydration. Poor turgor (skin "tents" or stays pinched) indicates dehydration.

What is the difference between a primary and a secondary skin lesion?

• Primary Lesion: A lesion that develops on previously unaltered skin (e.g., macule, papule, vesicle).

• Secondary Lesion: A lesion that results from a change in a primary lesion (e.g., a crust that forms from a ruptured vesicle, a scar, an ulcer).

What are the risk factors for skin cancer and the ABCDE assessment for cancerous lesions?

• Risk Factors: Sun exposure, fair skin, family history.

• ABCDE Assessment:

  • Asymmetry: One half does not match the other.

  • Border: Irregular, notched, or blurred.

  • Color: Varied shades of brown, black, red, or white.

  • Diameter: Greater than 6 mm (the size of a pencil eraser).

  • Evolving: Changes in size, shape, or color over time.

What are the risk factors for pressure ulcers and how are they staged?

• Risk Factors: Immobility, incontinence, poor nutrition, and altered sensation.

• Staging:

  • Stage 1: Non-blanchable redness of intact skin.

  • Stage 2: Partial-thickness skin loss (blister or abrasion).

  • Stage 3: Full-thickness skin loss into the subcutaneous tissue.

  • Stage 4: Full-thickness skin loss with exposure of muscle, bone, or tendon.

What are common skin changes in older adults?

• Decreased elasticity and thinning of the skin.

• Decreased subcutaneous fat, leading to a more bony appearance.

• Decreased blood supply to the skin, causing it to be drier and slower to heal.

What are the common causes of contact dermatitis?

Direct contact with an irritant or an allergen, such as poison ivy, chemicals, soaps, or metals like nickel.

What is a key precaution when a client has swallowing difficulties (dysphagia)?

Keep the client NPO (nothing by mouth) until a formal swallow evaluation is performed. Sit the client upright (90 degrees) if they are eating or drinking.

Where should the trachea be located, and what is an abnormal finding?

The trachea should be midline. A deviated trachea is an abnormal finding and can indicate a tension pneumothorax, a medical emergency.

How do you assess for a basilar skull fracture and the presence of cerebral spinal fluid (CSF) drainage?

• Signs: Bruising behind the ears (Battle's sign) or around the eyes (Raccoon eyes).

• CSF Assessment: Check any clear drainage from the nose or ears for glucose. The presence of glucose indicates CSF.

Define:

• Dysphasia

• Dysphagia

• Angioedema

• Anaphylaxis

• Dysphasia: Difficulty with speech.

• Dysphagia: Difficulty with swallowing.

• Angioedema: Swelling of the deep layers of the skin, often in the face and airway.

• Anaphylaxis: A severe, life-threatening allergic reaction.

Define:

• Ecchymosis

• Hematoma

• Purpura

• Petechiae

• Afebrile

• Ecchymosis: A bruise.

• Hematoma: A collection of blood under the skin.

• Purpura: Purple-colored spots and patches on the skin.

• Petechiae: Small, pinpoint red or purple spots on the skin.

• Afebrile: Without a fever.

What is a HIPAA breach of confidentiality?

Sharing a client's Protected Health Information (PHI) with anyone not directly involved in their care, or discussing client information in a public area where it can be overheard. PHI includes any information that can identify a client (e.g., name, DOB, medical record number) and their health status.