VSIM Jo Morrow Case 1 Exam Test latest Questions with Answers 2023 solution

VSIM Jo Morrow Case 1 Exam Test latest Questions with Answers 2023 solution 1. : Patient Introduction Location: Nursing home Time: 1000 Report from the charge nurse: Situation: Josephine Morrow is an obese, 80-year-old female who developed a venous stasis ulcer on her right lower extremity while still living at home. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown. Background: Mrs. Morrow has a past medical history of COPD, chronic venous in- sufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease was ruled out by duplex ultrasound. Her daughter recently moved her to this nearby nursing home due to concern for her safety related to impaired mobility, an unhealthy diet, and inability to adequately care for herself at home. Assessment: Mrs. Morrow is alert and oriented to person, time, and place but sometimes forgets recent events. Vital signs have been within normal limits and are performed weekly. Labs are done monthly, and results from yesterday are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and with getting out of bed to sit in a chair or ambulate. Her gait is unsteady and she is easily fatigued. Her last Braden scale assessment was conducted 2 days ago. She scored 14, indicating moderate risk. She has brown hyperpigmentation on both lower legs with +2 edema. The dressing was changed and the wound cleaned this morning. Recommendation: I would like you to complete a full-body skin assessment of Mrs. Morrow. You should also review the labs and do patient education on promotion of circulation and on maintaining good skin integrity. Health Assessment Weber, J.R., and Kelly, J.H. (2018). Health Assessment in Nursing, 6th Edition. Assessing Skin, Hair, and Nails, Chapter 14, pp. 247-279 Assessment Tool 14-1: Braden Scale for Predicting Pressure Sore Risk, Chapter 14, pp. 266-267 Abnormal Findings 22-1: Characteristics of arterial and Venous Insufficiency, Chapter 22, p. 488 Box 4-3: SBAR, Chapter 4, p. 58 Diseases and Conditions Expert Clinical Content from Lippincott Advisor Obesity, long-term care Varicose veins Diagnostic Tests Expert Clinical Content from Lippincott Advisor Albumin level test Complete blood count (CBC) with differential Prealbumin test Nursing Diagnosis Care Plans Expert Clinical Content from Lippincott Advisor Deficient knowledge: Disease process Impaired physical mobility Impaired skin integrity Signs and Symptoms Expert Clinical Content from Lippincott Advisor Edema (leg) Treatments Expert Clinical Content from Lippincott Advisor Wound care (pressure ulcer) Procedures Expert Clinical Content from Lippincott Procedures Skin assessment, long-term care 2. C,D,E: 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). A.Have you had any hair loss? B.Do you have a family history of keloids? C.What other symptoms occur with it? D.How much does it bother you? E.When did it begin? 3. A: The nurse is providing patient teaching about prevention of pressure ulcers. Which statement, if made by the patient, indicates that the teaching was success- ful? A.Because I have dry skin, I should avoid cold air and use moisturizers. B.When sitting in the chair, I should try to reposition myself every 2 hours. C.When I take a bath, I should use hot water. D.To stimulate circulation, it is important for me to vigorously massage my skin. 4. A,B,D: Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency. Which assessment findings would support this conclusion? (Select all that apply.) A.Moderate leg edema B.Thickened, tough skin C.Loss of hair over the toes and dorsum of the foot Reddish-blue discoloration D.Dependent rubor