Vsim 2

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 • Depth • Exudate • Borders • Asymmetry • Color

Asymmetry, color, & borders

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.) • Continence • Hydration • Mobility • Mental status • Nutrition

Nutrition & mobility

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

Palpation

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?

Stage II

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?

What other symptoms occur with it? , How much does it bother you? , When did it begin?

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? • papule • pustule • wheal • vesicle

vesicle

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

Capillary refill, texture, clubbing, & hygiene

The nurse is preparing to complete a skin, hair, and nail examination. What equipment should the nurse gather before beginning the assessment?

Penlight , Magnifying glass , Centimeter ruler

Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion? (Select all that apply.) • Reddish-blue discoloration • Moderate leg edema • Dependent rubor • Loss of hair on toes and dorsal • Thickened, tough skin

Reddish-blue discoloration, moderate leg edema, & thickened, tough skin

The nurse is providing patient teaching about prevention of pressure injuries. Which statement, if made by the patient, indicates that the teaching was successful? • Because I have dry skin, I should avoid cold air & use moisturizers • I should reposition myself every 2 hours when sitting on a chair • To promote circulation, I should vigorously massage skin • Bathe with hot water

• Because I have dry skin, I should avoid cold air & use moisturizers