MED-SURG Exam 1 (A+ GRADED)

What are the ABCDE's to identify skin cancer? correct answers A: Asymmetry of shape B: Border irregularity C: Color variation within one lesion D: Diameter > 6mm E: Evolving/changing features What are some psychosocial assessments for skin integrity? correct answers Body Image Body Language Social Isolation The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention? A- Symmetry B- Consistent color C- Diameter of 8mm D- Regular border correct answers Answer is C Which of the following is not a safe and effective care environment? A- Assist patients to change positions at least every 2 hours; noting any areas of comprised tissue integrity B Use lift sheets when moving pts with fragile skin to avoid sheering C- Use standard precautions when providing care to pts who have skin integrity D- Make sure to wash your hands after touching any areas of impaired skin integiry E- Position pts who are confined to bed to promote air circulation to skinfold areas to minimize pressure over bony prominences correct answers D- you should wash your hands BEFORE and AFTER What is an important aspect of physiological integrity? correct answers Ask any pt who has started taking a new prescription or OTC drug whether he or she has noticed any skin changes that occurred since taking the drug What are some ways for a nurse to promote health and maintenance with adults to prevent damage and cancer development? correct answers -Teach them to reduce sun exposure -To regularly use sunscreen -To examine their skin on a monthly basis for new changes and lesions -Teach pts to bathe, shampoo hair, and keep fingernails clean and trimmed What does red indicate for pressure mapping? What about blue? correct answers Areas of greater heat production and increased pressure loads. Blue indicates cooler areas under lower pressure What does a positive nitrogen balance require? correct answers An intake of 30 to 35 calories per kg of body weight with a protein intake of 1.25 to 1.5g/kg/day. Up to 2g/kg/day of protein may be needed when nutritional deficits are severe or protein loss is ongoing.