VSIM #2

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.)

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 educating Ms. Morrow and her daughter on food choices that will promote wound healing. Which diet choices should be included in the teaching session?

Meat, cheese, and beans

The nurse is assessing for 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.

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.)

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

Prealbumin 6 mg/dL

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

Reddish-blue discoloration; Moderate leg edema;Thickened, tough skin. 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 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 ulcer. A stage I pressure ulcer 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.

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.

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?

Venous Stasis Ulcer

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

Distribution, amount, lesions, condition

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 Ms. Morrow's skin. To which areas should the nurse pay extra attention during the assessment? (Select all that apply.)

Under the breasts, limbs, groin

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.)

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

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

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, Clubbing, Hygiene, Texture Rationale: The nurse should 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 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. Rationale:Because moisturizers help prevent skin breakdown, this statement (Because I have dry skin, I should avoid cold air and use moisturizers.) indicates the patient understood the teaching. The patient should be repositioned in the chair every 15 minutes rather than every 2 hours. A patient at risk for pressure ulcers should not vigorously massage skin. When bathing, warm water should be used rather than hot water.

Which statement, if made by Ms. Morrow, would indicate the need for additional teaching by the nurse?

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

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.)

Centimeter ruler, Magnifying glass, Penlight Rationale:The nurse should include a centimeter ruler, magnifying glass, and penlight. The measuring tape and goniometer would not be appropriate equipment for a skin, hair, and nail examination.

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.)

Nutrition; Mobility Rationale:The Braden scale includes categories for mobility and nutrition. The Braden Scale does not include a category for continence, hydration, or mental status.

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 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 it?; When did it begin?; How much does it bother you? Using a mnemonic such as COLDSP (character, onset, location, duration, severity, pain) 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 it?" (associated factors/manifestations), "When did it begin?" (onset), and "How much does it bother you?" (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 really do not have anything to do with the problem of rash and itching.