vSim Case 1

groin, limbs, under the breasts

the nurse is inspecting ms. morrow's skin. to which areas should the...

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

The nurse is interviewing a patient who is reporting itching and a rash. Which question would be appropriate for the nurse to include the nursing health history?

venous stasis ulcer

a nurse is assessing a wound in a patient's lower extremity that has a mottled, bluish appearance and localized edema. how should the nurse describe this type of wound?

color, border, asymmetry

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?

this tool will help me determine if you are at risk for developing pressure ulcers

ms. morrow asks "What is the Braden scale that you keep talking about?" What is the correct response by the nurse?

capillary refill, texture, hygiene, clubbing

the Nurse is assessing a patient's nails. which techniques should the nurse consider using when performing this assessment?

nutrition and mobility

the nurse completed a skin assessment and is now documenting using the Braden scale. which areas are assessed using this scale?

moderate leg edema, reddish- blue discoloration, thickened, tough skin

upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion?

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

which statement, if made by Ms. morrow, would indicate the need for additional teaching by the nurse?

because have dry skin, I should avoid cold air and use moisturizers

the nurse is providing patient teaching about prevention of pressure ulcers. which statement, if made by the patient, indicates that the teaching was successful?

leg pain and brownish or blue skin discoloration

the nurse is inspecting ms. morrow's leg for the development of additional venous states ulcers. which findings would alert the nurse to the possible development of an additional venous wound?

stage II

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

palpation

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

reddened are on the patient's heel

the nurse is completing a skin assessment of an older adult patient. which finding would require immediate action?

auscultation or palpation of peripheral pulses; comparison of one leg to another; palpation for warmth and tenderness; observation of legs for color and unusual vein patterns

the nurse is completing an assessment of a patient with lower extremity edema. what should the nurse include in the assessment?

meats, cheese, and beans

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?

vesicle

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?

centimeter ruler, magnifying glass, penlight

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

lesions, condition, amount, distribution

the nurse is preparing to inspect ms. morrow's hair and scalp. what should the nurse include in the assessment?

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

the nurse is providing teaching to Ms. morrow on how to prevent additional venous states ulcers. which statements would be appropriate to include in the teaching plan?

prealbumin 6 mg/dL

the nurse is reviewing Ms. Morrow's nutritional status. which laboratory value would be of most concern to the nurse