SIM Pretest JM

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

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

The nurse is assessing a patient's nails. Which techniques should the nurse consider using when performing this assessment? (SATA) Cap refill turgor clubbing texture hygiene

Cap refill clubbing texture hygiene

The nurse is preparing to complete a skin, hair, and nail examination. What equipment should the nurse gather before beginning the assessment? (SATA) Centimeter ruler Goniometer Penlight Measuring tape Magnifying glass

Centimeter ruler Penlight Magnifying glass

Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion? (SATA) Reddish-blue discoloration moderate leg edema loss of hair over the toes and dorsum of the foot thickened, tough skin dependent rubor

Reddish-blue discoloration moderate leg edema thickened, tough skin

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

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

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? (SATA) color depth asymmetry borders exudate

color asymmetry borders A: asymmetry B: borders C: color D: diameter

The nurse has completed a skin assessment and is now documenting using the Braden Scale. Which areas are assessed using this tool? (SATA) continence nutrition mental status mobility hydration

nutrition mobility

The nurse is assessing for skin texture, thickness, and moisture. Which technique would the nurse use to perform this assessment? auscultation inspection palpation percussion

palpation

The nurse is assessing a shallow, open ulcer with a re-pink wound bed that is located on a patient's sacrum. How would the nurse document this wound? Stage II Stage I Stage III Stage IV

stage II

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? wheal pustule papule vesicle

vesicle