health assessment case 1: josephine morrow

the nurse recognizes that josephine morrow is at a high risk for the development of _____ due to _____

deep vein thrombosis (DVT) decreased mobility

when inspecting a patient's cheek, the nurse finds a palpable, 0.4-cm mass containing clear fluid. how would the nurse document this finding?

vesicle

the nurse is providing patient teaching about prevention of pressure injuries. which statement by the patient would indicate that the teaching was successful?

"because i have dry skin, i should use moisturizers"

the nurse is interviewing a patient who is reporting itching and a rash. which question(s) would be appropriate for the nurse to include in the nursing health history? (select all that apply)

"what other symptoms occur with the rash?" "when did you first notice the rash?" "how much does the rash interfere with your daily activities?"

a patient with a history of skin cancer reports an "itchy mole" on the back. which characteristic(s) should the nurse inspect for when evaluating the lesion? (select all that apply)

asymmetry borders color

which of the following would the nurse examine as part of an assessment of a patient's nails? (select all that apply)

capillary refill clubbing hygiene texture

the nurse is inspecting Josephine Morrow's skin. To which areas should the nurse pay close attention while performing a physical assessment? (select all that apply)

groin sacrum arms and legs under the breasts

the nurse recognizes that josephine morrow's limited mobility can have adverse effects on the skin. what other information would the nurse need to gather to establish priorities for the plan of care? (select all that apply)

nutritional status circulation status smoking history hygiene status/practices fall risk

the nurse is assessing skin texture, thickness, and moisture. which technique would the nurse use to perform these assessments?

palpation

the nurse is preparing to complete a skin, hair, and nail examination. what equipment should the nurse gather before beginning the assessment? (select all that apply)

ruler or tape measure magnifying glass examination gown or drape penlight

the nurse is assessing a shallow, open ulcer with a red-pink would bed that is located on a patient's sacrum. how would the nurse document this wound?

stage ii

upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. which assessment findings would support this conclusion? (select all that apply)

thickened, tough skin moderate leg edema reddish-blue discoloration

the nurse is providing education to josephine morrow on how to prevent additional venous stasis ulcers from developing. which statement(s) would be appropriate to include in the teaching plan? (select all that apply)

wear support stockings to help prevent ulcers and heal existing ones watch for signs and symptoms of new ulcers

the nurse has completed a skin assessment and is now documenting using the Braden Scale. which area(s) are assessed using this tool? (select all that apply)

mobility nutrition

the nurse is evaluating josephine morrow's understanding of the plan of care to promote wound healing. the patient demonstrates understanding when she selects which of the following foods for her meal? (select all that apply)

milk broccoli orange chicken breast

in developing goals collaboratively with the patient, the nurse would write the following short-term priority goal in the care plan: the patient will _____ by _____

name three foods that contribute to wound healing the date of discharge