Nur 216 Exam 2 Test Questions

pressure injury stages {Ans: stage 1=see top layer of skin, stage 2= see through epidermis and dermis, stage 3= see subcutaneous tissue, stage 4= see bone or underlying structures, unstageable= ulcer covered with eschar or slough debridement required, deep tissue injury= discoloration but skin intact damage to underlying tissues appears as a bruise with intact skin}neck assessment techniques {Ans: inspect, palpate, auscultate}outer ear expected findings include? {Ans: some cerumen at opening of ear canal, intact skin, non-tender}nystagmus {Ans: Involuntary rapid eye movements/ vibration of eyes}focused assessment definition {Ans: partial assessment looking at one body system relating to the patient's chief complaint/symptoms}bulla: surface characteristics, examples {Ans: palpable, fluid filled, greater than 1cm; blister, med reaction, burns}