MED-SURG EXAM 1 WITH
CORRECT ANSWERS
2025
What are the ABCDE's to identify skin cancer? ( Correct answers ) A:
Asymmetry of
shap
B: Border
e
C: Color variation within one
irregularity
D: Diameter >
lesion
E: Evolving/changing
6mm
features
What are some psychosocial assessments for skin integrity? ( Correct
answers ) Body
Imag
Body
e
Language
Social
Isolation
The nurse is assessing a patient's skin. Which lesion finding requires
further nursing
interventio
n?
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
B Use lift sheets when moving pts with fragile skin to avoid
integrity
C- Use standard precautions when providing care to pts who have
sheering
skinMake
D- integrity
sure to wash your hands after touching any areas of impaired
skin
E- Position
integiry
pts who are confined to bed to promote air circulation to
skinfold areas
minimize pressure
to over bony prominences ( Correct answers ) D- you
should
your hands
washBEFORE and
AFTER
What is an important aspect of physiological integrity? ( Correct answers )
Ask any
who has pt
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
prevent damage
to and cancer development? ( Correct answers ) -Teach
them to reduce
sun
-To regularly use
exposure
sunscreen
GRADED
A+
, -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
Areas of greater
answersheat
) production and increased pressure loads. Blue
indicates
areas under
cooler
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.
So if a patient weighs 68kg they need at least 85g of
protein daily.
What are 3 things that are important to remember with skin care?
( Correct
1. Do not answers
massage) bony
prominences
2. Document and report any manifestations of skin
infection
3. Use moisturizers daily on dry skin and apply when
skin is damp
Explain a stage 1 pressure ulcer... ( Correct answers ) -The
skin isusually
-Area intact over bony prominence, does not blanch (lighten/turn
white) with
external pressure which indicates absence of capillary
blood
and flowtissue
early
damage
-Observable pressure-related alterations of intact skin
Explain stage 2 pressure ulcer ( Correct answers ) -Skin is
not intact
-Partial-thickness skin loss of epidermis or
dermis
-Ulcer is superficial, may appear as abrasion, blister, or
shallow crater
-Bruising not present
Explain stage 3 pressure ulcer ( Correct answers ) -Full-thickness
skin loss
-Subcutaneous tissue and underlying fascia may be damaged
or necrotic
-Bone, tendon, muscle NOT
-May have undermining and tunneling
exposed
Explain stage 4 pressure ulcer ( Correct answers ) -Full-thickness with
exposed or
palpable muscle, tendon, or
-Undermining and tunneling common with sinus tracts
bone
possible
-Slough and eschar often present (dead
tissue)
Nurses canNOT delegate this assessment to UAP because it is beyond
their scope
practice of
( Correct answers ) Nurses should also inspect the ENTIRE body
for location,
size, color, extent of tissue involvement and surrounding tissue, cell
types in wound
GRADED
A+
CORRECT ANSWERS
2025
What are the ABCDE's to identify skin cancer? ( Correct answers ) A:
Asymmetry of
shap
B: Border
e
C: Color variation within one
irregularity
D: Diameter >
lesion
E: Evolving/changing
6mm
features
What are some psychosocial assessments for skin integrity? ( Correct
answers ) Body
Imag
Body
e
Language
Social
Isolation
The nurse is assessing a patient's skin. Which lesion finding requires
further nursing
interventio
n?
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
B Use lift sheets when moving pts with fragile skin to avoid
integrity
C- Use standard precautions when providing care to pts who have
sheering
skinMake
D- integrity
sure to wash your hands after touching any areas of impaired
skin
E- Position
integiry
pts who are confined to bed to promote air circulation to
skinfold areas
minimize pressure
to over bony prominences ( Correct answers ) D- you
should
your hands
washBEFORE and
AFTER
What is an important aspect of physiological integrity? ( Correct answers )
Ask any
who has pt
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
prevent damage
to and cancer development? ( Correct answers ) -Teach
them to reduce
sun
-To regularly use
exposure
sunscreen
GRADED
A+
, -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
Areas of greater
answersheat
) production and increased pressure loads. Blue
indicates
areas under
cooler
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.
So if a patient weighs 68kg they need at least 85g of
protein daily.
What are 3 things that are important to remember with skin care?
( Correct
1. Do not answers
massage) bony
prominences
2. Document and report any manifestations of skin
infection
3. Use moisturizers daily on dry skin and apply when
skin is damp
Explain a stage 1 pressure ulcer... ( Correct answers ) -The
skin isusually
-Area intact over bony prominence, does not blanch (lighten/turn
white) with
external pressure which indicates absence of capillary
blood
and flowtissue
early
damage
-Observable pressure-related alterations of intact skin
Explain stage 2 pressure ulcer ( Correct answers ) -Skin is
not intact
-Partial-thickness skin loss of epidermis or
dermis
-Ulcer is superficial, may appear as abrasion, blister, or
shallow crater
-Bruising not present
Explain stage 3 pressure ulcer ( Correct answers ) -Full-thickness
skin loss
-Subcutaneous tissue and underlying fascia may be damaged
or necrotic
-Bone, tendon, muscle NOT
-May have undermining and tunneling
exposed
Explain stage 4 pressure ulcer ( Correct answers ) -Full-thickness with
exposed or
palpable muscle, tendon, or
-Undermining and tunneling common with sinus tracts
bone
possible
-Slough and eschar often present (dead
tissue)
Nurses canNOT delegate this assessment to UAP because it is beyond
their scope
practice of
( Correct answers ) Nurses should also inspect the ENTIRE body
for location,
size, color, extent of tissue involvement and surrounding tissue, cell
types in wound
GRADED
A+
