vSIM 1: Case Josephine Morrow

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 Depth Exudate

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 recognizes that Josephine Morrow is at a high risk for the development of [cyanosis, heart failure, arterial insufficiency, DVT] due to Choose Answer.. [loneliness, peripheral edema, decreased mobility, hyperpigmentation on both lower extremities]

DVT decreased mobility,

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.) Continence Hydration Mental status Mobility Nutrition

Mobility Nutrition

The nurse recognizes that Josephine Morrow's limited mobility can have adverse effects on the skin. What other information would the nurse need to gather to establish priorities for the plan of care? (Select all that apply.) Family history Nutritional status Smoking history Fall risk Circulation status Hygiene status/practices

nutritional status smoking history fall risk circulation status hygiene status/practices

The nurse is inspecting Josephine Morrow's skin. To which areas should the nurse pay close attention while performing a physical assessment? (Select all that apply.) Under the breasts Sacrum Hair and scalp Arms and legs Surface of the abdomen Groin Eye and ears

under the breasts groin arms and legs sacrum

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? Papule Pustule Vesicle Wheal

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 providing education to Josephine Morrow on how to prevent additional venous stasis ulcers from developing. Which statement(s) would be appropriate to include in the teaching plan? (Select all that apply.) 'Keep your blood sugar under 200 mg/dL.' 'Choose nonskid footwear with supportive soles.' 'Watch for signs and symptoms of new ulcers.' 'Install safety rails in your bathroom, including a grab bar in the shower.' 'Wear support stockings to help prevent ulcers and heal existing ones.' 'Participate in activities that require aerobic activity and physical contact to promote circulation.'

'Watch for signs and symptoms of new ulcers.' 'Wear support stockings to help prevent ulcers and heal existing ones.'

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 Goniometer Penlight

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? 'When sitting in the chair, I should try to reposition myself every 2 hours.' 'To stimulate circulation, it is important for me to vigorously massage my skin.' 'When I take a bath, I should use hot water.' 'Because I have dry skin, I should use moisturizers.'

'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.

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?' 'Do you have a family history of keloids?' 'Have you had any hair loss?'

'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.

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

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

The nurse is evaluating Josephine Morrow's understanding of the plan of care to promote wound healing. The patient demonstrates understanding when she selects which of the following foods for her meal? (Select all that apply.) Broccoli Apple Chicken breast White rice Orange Cereal Milk

broccoli chicken breast orange milk

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

palpation

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 Turgor

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 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 I Stage II Stage III Stage IV

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.