Page 366 - Saunders Comprehensive Review For NCLEX-RN

4. Refer to Chapter 42 for diagnostic tests related to the
integumentary system

To test skin turgor, pinch a large fold of skin and assess the

ability of the skin to return to its place when released. Poor turgor occurs
in severe dehydration or extreme weight loss.

5. Client teaching

a. Provide information about factors that
can be harmful to the skin, such as sun
exposure.
b. Encourage performing self-examination
of the skin for lesions monthly using
the ABCDE (asymmetry, border
irregularity, color variance, diameter
greater than 6 mm, evolving size,
shape, and color) mnemonic.
B. Head, neck, and lymph nodes: Involves inspection, palpation, and
auscultation of the head, neck, and lymph nodes
1. Ask the client about headaches; episodes of dizziness
(lightheadedness) or vertigo (spinning sensation);
history of head injury; loss of consciousness; seizures;
episodes of neck pain; limitations of range of motion;
numbness or tingling in the shoulders, arms, or
hands; lumps or swelling in the neck; difficulty
swallowing; medications being taken; and history of
surgery in the head and neck region.
2. Head
a. Inspect and palpate: Size, shape, masses
or tenderness, and symmetry of the
skull
b. Palpate temporal arteries, located above
the cheekbone between the eye and the
top of the ear.
c. Palpate frontal and maxillary sinuses
for tenderness.
d. Temporomandibular joint: Ask the
client to open his or her mouth and
move it from side to side; note any
crepitation, tenderness, or limited
range of motion. This tests cranial
nerve V, the trigeminal nerve.
e. Face: Inspect facial structures for shape,
symmetry, involuntary movements, or
swelling, such as periorbital edema
(swelling around the eyes).

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