Jo Morrow Case 1

a

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

c

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 IV Stage III Stage II Stage I

abd

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

abcd

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

b

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

ace

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

cde

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

abc

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.) Magnifying glass Centimeter ruler Penlight Measuring tape Goniometer

a

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

a

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

Asymmetry Color Borders

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.) Exudate Asymmetry Depth Color Borders

a

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? Leg pain and brownish or blue skin discoloration Diminished pulses in the affected extremity Pallor in the lower extremity Dependent rubor

d

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? Green, leafy vegetables Whole wheat bread and brown rice Cereals and fruits Meats, cheese, and beans

b

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 Vesicle Pustule Wheal

abce

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.) Observation of legs for color and unusual vein patterns Comparison of one leg to another Palpation for warmth and tenderness Measurement of leg circumference at different anatomical levels Auscultation or palpation of peripheral pulses

b

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

a

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

bc

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.) Hydration Mobility Nutrition Mental status Continence

abcd

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 Hygiene Turgor

c

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? Arterial ulcer Stage III pressure ulcer Venous stasis ulcer Unstageable pressure ulcer

cd

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.) Participate in activities that require physical contact to promote circulation. Choose footwear that is nonskid with a low heel. Watch for signs and symptoms of new ulcers. Wear support stockings to help prevent ulcers and heal existing ones. Install safety rails in your bathroom to help prevent falls.