VSIM PRE QUIZ Josephine Morrow

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 Rationale:Before a skin, hair, and nail examination, the nurse should gather an examination gown, a ruler or tape measure, a magnifying glass, and a penlight. A goniometer would not be appropriate equipment for a skin, hair, and nail examination.

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.' Rationale:Because moisturizers help prevent skin breakdown, the statement 'Because I have dry skin, I should use moisturizers' indicates the patient understood the teaching. The patient should be repositioned in the chair every 15 minutes rather than every 2 hours. When bathing, warm water should be used rather than hot water. A patient at risk for pressure injuries should not vigorously massage skin because doing so could lead to tissue damage including tearing of the skin, bruising of deep tissue, and pain.

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 Rationale:The nurse would test capillary refill and should inspect for clubbing, hygiene, and texture. Turgor is a measure of hydration status and is not part of an assessment of the nails.

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 Rationale:The Braden Scale includes categories for mobility and nutrition. The Braden Scale does not include categories for continence, hydration, or mental status.

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

Palpation Rationale:The nurse uses palpation, or touch, to assess the skin's texture, thickness, and moisture.

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 Rationale:Thickened skin, moderate leg edema, and reddish-blue discoloration of the lower extremity are all characteristic of venous insufficiency. Dependent rubor and loss of hair are associated with arterial insufficiency.

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 Rationale:A palpable mass containing clear serous fluid that is less than 0.5 cm is a vesicle. A papule is an elevated, solid mass; a pustule is a pus-filled vesicle; and a wheal is an elevated mass with transient borders.

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?' Rationale:Using a mnemonic such as COLDSPA (character, onset, location, duration, severity, pain, and associated factors) or OLDCART (onset, location, duration, characteristic symptoms, associated manifestations, relieving/exacerbating factors, and treatment), appropriate questions for a patient experiencing a rash can include: 'What other symptoms occur with the rash?' (associated factors/manifestations), 'When did you first notice the rash?' (onset), and 'How much does the rash interfere with your daily activities?' (severity/characteristic symptoms). Although 'Do you have a family history of keloids?' and 'Have you had any hair loss?' may be included in health history related to skin, hair, and nails, they do not relate to the problem of rash and itching.

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 Rationale:The ABCDE mnemonic is used when inspecting a cancerous lesion: A for asymmetry, B for borders, C for color, D for diameter, and E for elevation. Depth and exudate would be important factors when assessing wounds, not moles.

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 Rationale:A shallow, open ulcer with a red-pink wound bed would be documented as a stage II pressure injury. A stage I pressure injury is an area of intact skin with nonblanchable redness. Stage III is full-thickness tissue loss. Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle.