Health Asses 16

Skin Examination

The nurse should wear gloves when preparing to inspect the skin and nails.

Self-Examination Frequency

The nurse encourages the patient to perform skin self-examination monthly.

Lesion Configuration

The nurse documents the configuration of distinct lesions as discrete.

Beau's Lines

The presence of Beau's lines suggests acute illness.

Braden Scale

The nurse evaluates the patient's ability to change position when using the Braden Scale.

Childhood Sunburns

The nurse explains that childhood sunburns increase the risk of skin cancer later in life.

Infection Control

The nurse should wear gloves when palpating lesions on the patient's skin.

Bluish Nail Beds

A bluish tone in nail beds is most likely attributable to hypoxemia.

Stage I Pressure Ulcer

A nonblanching reddened area on the coccyx indicates a stage I pressure ulcer.

Fungal Lesions

The nurse can corroborate fungal suspicion by illuminating the area using a Wood's light.

Uncharacteristic Facial Hair

The nurse should ask if the patient has ever been assessed for diabetes.

Depigmentation

Distinct regions of depigmentation in dark-skinned patients indicate vitiligo.

Braden Scale Health Status

Consistent urinary incontinence would be reflected in the Braden Scale score.

Macules Characteristic

Macules will not be palpable.

Temporal Artery Palpation

The nurse places hands anterior and inferior to the ears to palpate the temporal artery.

Carotid Pulses Contraindication

Compressing the arteries bilaterally is contraindicated when assessing carotid pulses.

Cranial Nerve Deficit

The inability to turn the head against resistance suggests a deficit in the accessory (XI) cranial nerve.

Intermittent Facial Pain

This complaint is suggestive of trigeminal neuralgia.

Migraines

Visual changes before the headache suggest that the headaches are migraines.

Head and Neck Assessment Alert

Alcohol abuse alerts the nurse to perform a more thorough head and neck assessment.

Traumatic Brain Injury Prevention

Falls prevention is a leading measure to prevent traumatic brain injury.

Larger Skull and Facial Bones

Larger and thicker skull and facial bones may indicate acromegaly.

Patient Head Tilt

The nurse should first examine the patient's hearing acuity.

Temporal Artery Assessment

A hard, thick, and tender temporal artery with absent pulsations requires additional information related to vision.

Thyroid Gland Examination

The nurse needs additional instruction if they do not demonstrate proper palpation technique.

Trachea Palpation

The nurse first positions a finger for trachea palpation at the sternal notch.