JOSEPHINE MORROW VSIM CASE TEST WITH SOLUTIONS
#6
Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency.
Which assessment findings would support this conclusion? (Select all that apply.) -
correct answer Moderate leg edema,Thickened, tough skin,Reddish-blue discoloration
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.
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.) - correct answer Color,Borders,Asymmetry
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 assessing a patient's nails. Which techniques should the nurse consider
using when performing this assessment? (Select all that apply.) - correct answer
Capillary refill,Texture,Clubbing,Hygiene
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? - correct
answer 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.
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.) - correct
answer Nutrition,Mobility
He 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? - correct answer
Stage II
#6
Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency.
Which assessment findings would support this conclusion? (Select all that apply.) -
correct answer Moderate leg edema,Thickened, tough skin,Reddish-blue discoloration
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.
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.) - correct answer Color,Borders,Asymmetry
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 assessing a patient's nails. Which techniques should the nurse consider
using when performing this assessment? (Select all that apply.) - correct answer
Capillary refill,Texture,Clubbing,Hygiene
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? - correct
answer 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.
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.) - correct
answer Nutrition,Mobility
He 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? - correct answer
Stage II
