VSim Case 1- Josephine Morrow

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 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).

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

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

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

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

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

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 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

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?

meats, cheeses, and beans

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.)

mobility, nutrition

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

palpation

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-bluish discoloration, thickened, tough skin, moderate leg edema

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

Amount, Condition, Distribution, Lesions

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, Auscultation or palpation of peripheral pulses, Palpation for warmth and tenderness, Comparison of one leg to another

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

Prealbumin 6 mg/dL

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 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.)

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

The nurse is assessing a patient's nails. Which techniques should the nurse consider using when performing this assessment? (Select all that apply.)

clubbing, capillary refill, hygiene, texture

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