Hondros 205 Exam 2 study Questions
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Focused assessment - correct answer -A focused assessment in nursing
is a targeted and systematic examination of a patient's specific body
systems or issues, often conducted in response to a particular clinical
concern or to gather information relevant to the patient's current
health condition. It is a more narrowly scoped evaluation compared to a
comprehensive assessment, which covers a broader range of bodily
systems and functions.
What musculoskeletal system includes on a basic level - correct answer
-The musculoskeletal system plays a crucial role in supporting the
body's weight, maintaining posture, protecting vital organs, and
enabling various types of movement, including walking, running, and
fine motor skills. It is essential for overall mobility and the performance
of daily activities.
,Braden Scale for Predicting Pressure Sore Risk - correct answer -The risk
factors in the Braden Scale include:
Sensory Perception: This factor assesses the patient's ability to perceive
pressure and discomfort. It considers the patient's mental state and
their ability to respond to discomfort or pain.
Moisture: This factor evaluates the degree of moisture present on the
patient's skin, considering factors like incontinence and perspiration.
Activity: This assesses the patient's mobility level and ability to change
positions independently.
Mobility: This factor evaluates the patient's ability to change and
control body position.
Nutrition: It considers the patient's nutritional status and overall health,
which can affect skin integrity.
Friction and Shear: This factor takes into account the effects of friction
and shear forces on the patient's skin. Friction occurs when the skin
rubs against another surface, and shear occurs when layers of tissue
slide over one another.
What to look for during skin assessment? - correct answer -
Temperature: Assess skin temperature for warmth or coolness, which
can indicate circulation problems.
Texture: Feel for changes in skin texture, like dryness, roughness, or
excessive moisture.
, Turgor: Test skin turgor by gently pinching the skin; poor turgor can
indicate dehydration.
Edema: Detect any swelling or pitting edema (skin indentation that
persists after pressure) in the legs, feet, or other areas.
Moisture: Check for excessive sweating or dryness.
Stages of pressure ulcers - correct answer -Stage I: nonblanchable
erythema of intact skin
Stage II: partial-thickness skin loss
Stage III: full-thickness skin loss; not involving underlying fascia
Stage IV: full-thickness skin loss with extensive destruction
Unstageable: base of ulcer covered by slough and/or eschar in wound
bed
Stage 1 pressure ulcer - correct answer -Stage 1:
Characteristics: The skin is intact but appears red, and it may feel
warmer or cooler than the surrounding skin. It may also be firm or soft
to the touch.
Symptoms: Pain, itching, or a burning sensation may be present.
and Answers 100% Pass |Already
Graded A+| Verified and Updated
Focused assessment - correct answer -A focused assessment in nursing
is a targeted and systematic examination of a patient's specific body
systems or issues, often conducted in response to a particular clinical
concern or to gather information relevant to the patient's current
health condition. It is a more narrowly scoped evaluation compared to a
comprehensive assessment, which covers a broader range of bodily
systems and functions.
What musculoskeletal system includes on a basic level - correct answer
-The musculoskeletal system plays a crucial role in supporting the
body's weight, maintaining posture, protecting vital organs, and
enabling various types of movement, including walking, running, and
fine motor skills. It is essential for overall mobility and the performance
of daily activities.
,Braden Scale for Predicting Pressure Sore Risk - correct answer -The risk
factors in the Braden Scale include:
Sensory Perception: This factor assesses the patient's ability to perceive
pressure and discomfort. It considers the patient's mental state and
their ability to respond to discomfort or pain.
Moisture: This factor evaluates the degree of moisture present on the
patient's skin, considering factors like incontinence and perspiration.
Activity: This assesses the patient's mobility level and ability to change
positions independently.
Mobility: This factor evaluates the patient's ability to change and
control body position.
Nutrition: It considers the patient's nutritional status and overall health,
which can affect skin integrity.
Friction and Shear: This factor takes into account the effects of friction
and shear forces on the patient's skin. Friction occurs when the skin
rubs against another surface, and shear occurs when layers of tissue
slide over one another.
What to look for during skin assessment? - correct answer -
Temperature: Assess skin temperature for warmth or coolness, which
can indicate circulation problems.
Texture: Feel for changes in skin texture, like dryness, roughness, or
excessive moisture.
, Turgor: Test skin turgor by gently pinching the skin; poor turgor can
indicate dehydration.
Edema: Detect any swelling or pitting edema (skin indentation that
persists after pressure) in the legs, feet, or other areas.
Moisture: Check for excessive sweating or dryness.
Stages of pressure ulcers - correct answer -Stage I: nonblanchable
erythema of intact skin
Stage II: partial-thickness skin loss
Stage III: full-thickness skin loss; not involving underlying fascia
Stage IV: full-thickness skin loss with extensive destruction
Unstageable: base of ulcer covered by slough and/or eschar in wound
bed
Stage 1 pressure ulcer - correct answer -Stage 1:
Characteristics: The skin is intact but appears red, and it may feel
warmer or cooler than the surrounding skin. It may also be firm or soft
to the touch.
Symptoms: Pain, itching, or a burning sensation may be present.
