VSIM 1- CASE TEST JOSEPHINE MORROW FULLY
RESOLVED #7
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.' - correct answer '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 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 - correct answer 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.
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?' - correct answer '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.
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 - correct answer 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 assessing skin texture, thickness, and moisture. Which technique would
the nurse use to perform these assessments?
Inspection
Palpation
Percussion
Auscultation - correct answer 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 - correct answer Capillary refill
Clubbing
Hygiene
Texture
RESOLVED #7
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.' - correct answer '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 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 - correct answer 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.
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?' - correct answer '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.
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 - correct answer 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 assessing skin texture, thickness, and moisture. Which technique would
the nurse use to perform these assessments?
Inspection
Palpation
Percussion
Auscultation - correct answer 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 - correct answer Capillary refill
Clubbing
Hygiene
Texture
