vSIMS #1 Questions

A patient with a history of skin cancer reports an "itchy mole" on the back. Which characteristics should the nurse inspect for when evaluating the lesion? (select all that apply) a. Asymmetry b. Color c. Exudate d. Borders e. Depth

a. Asymmetry b. Color d. Borders

The nurse is providing patient teaching about prevention of pressure ulcers. Which statement, if made by the patient, indicates that the teaching was successful? a. To stimulate circulation, it is important for me to vigorously massage my skin b. Because I have dry skin, I should avoid cold air and use moisturizers c. When sitting in the chair, I should try to reposition myself every 2 hours. d. When I take a bath, I should use hot water

b. Because I have dry skin, I should avoid cold air and use moisturizers

The nurse is inspecting a patient's cheek and finds a palpable, 0.4-cm mass containing clear fluid. How would the nurse document this finding? a. Papule b. Pustule c. Wheal d. Vesicle

d. Vesicle

The nurse is inspecting Ms. Morrow's skin. To which areas should the nurse pay extra attention during the assessment (select all that apply) a. Under the breasts b. Surface of the abdomen c. Hair and scalp d. Groin e. Limbs

a. Under the breasts d. Groin e. Limbs

The nurse is educating Ms. Morrow and her daughter on food choices that will promote wound healing. Which diet choices should be included in the teaching session? a. Green, leafy vegetables b. Cereals and fruits c. Meats, cheese, and beans d. Whole wheat bread and brown rice

c. Meats, cheese, and beans

The nurse is assessing a wound on a patient's lower extremity that has a mottled, bluish appearance and localized edema. How should the nurse describe this type of wound? a. Stage III Pressure ulcer b. Arterial ulcer c. Unstageable pressure ulcer d. Venous stasis ulcer

d. Venous stasis ulcer

The nurse is completing a skin assessment of an older adult patient. Which finding would require immediate attention? a. Striae on the abdomen and thighs b. Reddened area on the patient's heel c. Small, flat macules on both shoulders d. A raised nevus on the back of the neck

b. Reddened area on the patient's heel

Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion? (select all that apply) a. Loss of hair over the toes and dorsum of the foot b. Moderate leg edema c. Reddish-blue discoloration d. Dependent rubor e. Thickened, tough skin

b. Moderate leg edema c. Reddish-blue discoloration e. Thickened, tough skin

The nurse is assessing a shallow, open ulcer with a red-pink wound bed that is located on a patient's sacrum. How would the nurse document this wound? a. Stage I b. Stage II c. Stage IV d. Stage III

b. Stage II

The nurse is assessing for skin texture, thickness, and moisture. Which technique would the nurse use to perform these assessments? a. Auscultation b. Inspection c. Palpation d. Percussion

c. Palpation

Ms. Morrow asks "What is the Braden scale that you keep talking about?" What is the correct response by the nurse? a. This assessment will help me find out if you will be able to take care of yourself at home. b. It is a tool to determine whether or not you are at risk for falls. c. This tool will help me determine if you are at risk for developing pressure ulcers. d. It is a technique used to identify common problems in older adults.

c. This tool will help me determine if you are at risk for developing pressure ulcers.

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) a. Centimeter ruler b. Magnifying glass c. Measuring tape d. Goniometer e. Penlight

a. Centimeter ruler b. Magnifying glass e. Penlight

The nurse is preparing to inspect Ms. Morrow's hair and scalp. What should the nurse include in the assessment? (select all that apply) a. Condition b. Distribution c. Length d. Lesions e. Amount

a. Condition b. Distribution d. Lesions e. Amount

The nurse is inspecting Ms. Morrow's leg for the development of additional venous stasis ulcers. Which findings would alert the nurse to the possible development of an additional venous wound? a. Leg pain and brownish or blue skin discoloration b. Diminished pulses in the affected extremity c. Pallor in the lower extremity d. Dependent rubor

a. Leg pain and brownish or blue skin discoloration

The nurse is assessing a patient's nails. Which techniques should the nurse consider using when performing this assessment? (select all that apply) a. Hygiene b. Turgor c. Clubbing d. Capillary refill e. Texture

a. Hygiene c. Clubbing d. Capillary refill e. Texture

Which statement, if made by Ms. Morrow, would indicate the need for additional teaching by the nurse? a. I can expect my wound to heal in 1 to 3 months. b. I should let my nurse know if the wound gets bigger, starts to hurt more, or smells bad. c. My caregivers should follow the provider's instructions precisely when changing the dressing. d. I should keep the wound clean to prevent it from becoming infected.

a. I can expect my wound to heal in 1 to 3 months.

The nurse has completed a skin assessment and is now documenting using the Braden Scale. Which areas are assessed using this tool? (select all that apply) a. Mobility b. Hydration c. Mental status d. Nutrition e. Continence

a. Mobility d. Nutrition

The nurse is completing an assessment of a patient with lower extremity edema. What should the nurse include in the assessment? (select all that apply) a. Observation of legs for color and unusual vein patterns b. Auscultation or palpation of peripheral pulses c. Comparison of one leg to another d. Measurement of leg circumference at different anatomical levels e. Palpation for warmth and tenderness

a. Observation of legs for color and unusual vein patterns b. Auscultation or palpation of peripheral pulses c. Comparison of one leg to another e. Palpation for warmth and tenderness

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) a. When did it begin? b. Have you had any hair loss? c. How much does it bother you? d. What other symptoms occur with it? e. Do you have a family history of keloids?

a. When did it begin? c. How much does it bother you? d. What other symptoms occur with it?

The nurse is reviewing Ms. Morrow's nutritional status. Which laboratory value would be of most concern to the nurse? a. Potassium 4.0 mEq/L b. Prealbumin 6 mg/dL c. Urine protein 60 mg/ 24 hours d. Albumin 5.2 g/dL

b. Prealbumin 6 mg/dL

The nurse is providing teaching to Ms. Morrow on how to prevent additional venous stasis ulcers. Which statements would be appropriate to include in the teaching plan? (select all that apply) a. Install safety rails in your bathroom to help prevent falls. b. Watch for signs and symptoms of new ulcers. c. Participate in activities that require physical contact to promote circulation d. Wear support stockings to help prevent ulcers and heal existing ones e. Choose footwear that is nonskid with a low heel.

b. Watch for signs and symptoms of new ulcers. d. Wear support stockings to help prevent ulcers and heal existing ones