PrepU Skin Assesment Practice

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

Vesicle

A client has a nursing diagnosis of fluid volume deficit. Which of the following nursing assessment findings would support this diagnosis?

Orthostatic blood pressure changes

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the

changes from the normal expected findings.

Which action would be most helpful in preventing pressure ulcer formation in an at-risk client?

repositioning every hour

Which is the most accurate method of determining the extent of a client's fluid loss?

weighing the client

An older adult has several ecchymotic areas on the left arm. The nurse should further assess the client for:

Increased capillary fragility and permeability

Upon repositioning an immobile client, the nurse notes redness with blanching over a bony prominence. What is the most probable cause?

The reactive hyperemia is likely transient.

When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:

laceration.

An elderly client who is 5 feet, 4 inches (163 cm) and weighs 145 lb (65 kg) is admitted to the long-term care facility. The client sits for long periods in a wheelchair and has bowel and bladder incontinence. He can feed himself and has a fair appetite, eating best at breakfast and poorly thereafter. He doesn't have family members living nearby and is often noted to be crying and depressed. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? Select all that apply.

Incontinence Sitting for long periods Sedation