Questions PRE-POST QUIZ Vsims Josephine Morrow PDF

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Josephine Morrow Health Assessment pre-and post- quiz questions...

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Health Assessment Case 1: Josephine Morrow

The workflow below is a suggested learning path. You may complete the materials more than once. However, you cannot access the post-simulation quiz, documentation assignments, and guided reflection questions until you have completed the vSim once.

1. 2. 3. 4. 5. 6.

1 Suggested Reading 2 Pre-Simulation Quiz 3 vSim 4 Post-Simulation Quiz 5 Documentation Assignments 6 Guided Reflection Questions

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 insufficiency, 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.

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

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 1. Weber, J.R. and Kelley, J.H. (2018) Health Assessment in Nursing, 6th Edition. 2. Assessing Skin, Hair, and Nails, Chapter 14, pp. 247-279 3. Assessment Tool 14-1: Braden Scale for Predicting Pressure Sore Risk, Chapter 14, pp. 266-267 4. Abnormal Findings 22-1: Characteristics of arterial and Venous Insufficiency, Chapter 22, p. 488 5. Box 4-3: SBAR, Chapter 4, p. 58 Diseases and Conditions 1. Expert Clinical Content from Lippincott Advisor

2. Obesity, long-term care Obesity, long-term care 3. Varicose veins Varicose veins Diagnostic Tests 1. Expert Clinical Content from Lippincott Advisor

2. Albumin level test Albumin level test 3. Complete blood count (CBC) with differential Complete blood count (CBC) with differential

4. Prealbumin test Prealbumin test Nursing Diagnosis Care Plans 1. Expert Clinical Content from Lippincott Advisor

2. Deficient knowledge: Disease process Deficient knowledge: Disease process

3. Impaired physical mobility Impaired physical mobility 4. Impaired skin integrity Impaired skin integrity

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

Signs and Symptoms 1. Expert Clinical Content from Lippincott Advisor

2. Edema (leg) Edema (leg) Treatments 1. Expert Clinical Content from Lippincott Advisor

2. Wound care (pressure ulcer) Wound care (pressure ulcer) Procedures 1. Expert Clinical Content from Lippincott Procedures

2. Skin assessment, long-term care Skin assessment, long-term care PREQUIZ The nurse is preparing to complete a skin, hair, and nail examination. What equipment should the nurse gather before beginning the assessment? (Select all that apply.) a) Magnifying glass b) Goniometer c) Penlight d) Measuring tape e) Centimeter ruler

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). From vSim for Nursing | Health Assessment. © Wolters Kluwer.

a) Have you had any hair loss? b) Do you have a family history of keloids? c) How much does it bother you? d) When did it begin? e) What other symptoms occur with it?

The nurse is providing patient teaching about prevention of pressure ulcers. Which statement, if made by the patient, indicates that the teaching was successful? a) When I take a bath, I should use hot water. b) Because I have dry skin, I should avoid cold air and use moisturizers. c) When sitting in the chair, I should try to reposition myself every 2 hours. d) To stimulate circulation, it is important for me to vigorously massage my skin.

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

The nurse is assessing for skin texture, and moisture. Which technique would the nurse use to perform this assessment? A-auscultation B- inspection C-palpation D PERCUSSION

The nurse is assessing a patient’s nails. Which techniques should the nurse consider using when performing this assessment? (Select all that apply.) a) Texture b) Clubbing c) Capillary refill d) Hygiene e) Turgor From vSim for Nursing | Health Assessment. © Wolters Kluwer.

The 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? a) Stage I b) Stage IV c) Stage II d) Stage III

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) Loss of hair over the toes and dorsum of the foot b) Thickened, tough skin c) Reddish-blue discoloration d) Moderate leg edema e) Dependent rubor From vSim for Nursing | Health Assessment. © Wolters Kluwer.

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.) a) Continence b) Mobility c) Hydration d) Mental status e) Nutrition

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.) a) Borders b) Asymmetry c) Color d) Exudate e) Depth From vSim for Nursing | Health Assessment. © Wolters Kluwer.

The nurse is inspecting a patient’s cheek and finds a palpable, 0.4-cm mass containing clear fluid. How would the nurse document this finding? a) Papule b) Vesicle c) Pustule d) Wheal

1.The nurse is reviewing Ms. Morrow’s nutritional status. Which laboratory value would be of most concern to the nurse? a) Potassium 4.0 mEq/L b) Urine protein 60 mg/24 hours c) Albumin 5.2 g/dL d) Prealbumin 6 mg/dL

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

2. The nurse is inspecting Ms. Morrow’s skin. To which areas should the nurse pay extra attention during the assessment? (Select all that apply.) a) Under the breasts b) Hair and scalp c) Limbs d) Surface of the abdomen e) Groin

3. Ms. Morrow asks “What is the Braden scale that you keep talking about?” What is the correct response by the nurse? a) This tool will help me determine if you are at risk for developing pressure ulcers. From vSim for Nursing | Health Assessment. © Wolters Kluwer.

b) It is a tool to determine whether or not you are at risk for falls. c) This assessment will help me find out if you will be able to take care of yourself at home. d) It is a technique used to identify common problems in older adults.

4. The nurse is completing a skin assessment of an older adult patient. Which finding would require immediate attention? a) A raised nevus on the back of the neck b) Reddened area on the patient’s heel c) Small, flat macules on both shoulders d) Striae on the abdomen and thighs

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

5. The nurse is assessing a wound on a patient’s lower extremity that has a mottled, bluish appearance and localized edema. How should the nurse describe this type of wound? a) Arterial ulcer b) Stage III pressure ulcer c) Unstageable pressure ulcer d) Venous stasis ulcer

6. The nurse is providing teaching to Ms. Morrow on how to prevent additional venous stasis ulcers. Which statements would be appropriate to include in the teaching plan? (Select all that apply.) a) Choose footwear that is nonskid with a low heel. b) Participate in activities that require physical contact to promote From vSim for Nursing | Health Assessment. © Wolters Kluwer.

circulation. c) Watch for signs and symptoms of new ulcers. d) Wear support stockings to help prevent ulcers and heal existing ones. e) Install safety rails in your bathroom to help prevent falls.

7. Which statement, if made by Ms. Morrow, would indicate the need for additional teaching by the nurse? a) I can expect my wound to heal in 1 to 3 months. b) I should keep the wound clean to prevent it from becoming infected. c) I should let my nurse know if the wound gets bigger, starts to hurt more, or smells bad. d) My caregivers should follow the provider’s instructions precisely when changing the dressing.

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

8. The nurse is inspecting Ms. Morrow’s leg for the development of additional venous stasis ulcers. Which findings would alert the nurse to the possible development of an additional venous wound? a) Dependent rubor b) Leg pain and brownish or blue skin discoloration c) Diminished pulses in the affected extremity d) Pallor in the lower extremity

9. The nurse is educating Ms. Morrow and her daughter on food choices that will promote wound healing. Which diet choices should be included in the teaching session? a) Cereals and fruits b) Meats, cheese, and beans c) Whole wheat bread and brown rice From vSim for Nursing | Health Assessment. © Wolters Kluwer.

d) Green, leafy vegetables

10. The nurse is preparing to inspect Ms. Morrow’s hair and scalp. What should the nurse include in the assessment? (Select all that apply.) a) Condition b) Lesions c) Distribution d) Amount e) Length

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

11. The nurse is completing an assessment of a patient with lower extremity edema. What should the nurse include in the assessment? (Select all that apply.) a) Comparison of one leg to another b) Auscultation or palpation of peripheral pulses c) Palpation for warmth and tenderness d) Observation of legs for color and unusual vein patterns e) Measurement of leg circumference at different anatomical levels

From vSim for Nursing | Health Assessment. © Wolters Kluwer....