Vsim pre and post quiz questions

Ms. Morrow asks what the Braden scale is. What is the correct response?

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

Which statement by the patient would indicate a need for additional teaching by the nurse?

I can expect the wound to heal in 1-3 months.

The nurse is educating the patient and her daughter on food choices that will promote wound healing. Which diet choices should be included in the teaching session?

Meats, cheese, and beans

The nurse is assessing a shallow, open ulcer with 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 questions would be appropriate for the nurse to include in the nursing health history?

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

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

Centimeter Ruler, Magnifying glass, Penlight

A patient with a history of skin cancer reports an "itchy mole" on the back. Which characteristics should the nurse inspect when evaluating the lesion?

Color, Asymmetry, Borders

The nurse has completed a skin assessment and is now documenting using the Braden Scale. Which area are assessed using this tool?

Mobility, Nutrition

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

Prealbumin 6 mg/dL

The nurse is providing teaching to the patient on how to prevent venous stasis ulcers. Which statements would be appropriate to include in the teaching plan?

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

The nurse is preparing to inspect the patient's hair and scalp. What should the nurse include in the assessment?

Distribution, amount, lesions, condition

The nurse is inspecting the patients leg for the development of additional venous stasis ulcers. Which findings would alert the nurse to the possible development of an additional venous ulcer?

Leg pain and brownish or blue skin discoloration

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

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

The nurse is checking for skin thickness, texture, and moisture. Which technique would the nurse use tp preform these assessment?

Palpation

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

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

The nurse is completing a skin assessment of an older adult patient. Which finding would require immediate attention?

Reddened flat area on patient's heel

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?

Vesicle

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.

The nurse is assessing the patients nails. Which techniques should the nurse consider using when performing this assessment?

Capillary refill, clubbing, hygiene, texture

The nurse is inspecting Ms. Morrow's skin. To which areas should the nurse pay extra attention to during the assessment?

Under the breasts, limbs, groin

The nurse is assessing a wound on a patient's lower extremity that has a mottled, blush appearance and localized edema. How should the nurse describe this type of wound?

Venous Stasis Ulcer