Josephine Morrow | Questions and Answers with complete solution

Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion? (Select all that apply.) - 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.) - 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.) - 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? - 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.) - Nutrition,Mobility