Question

In: Nursing

The nurse finds that the skin over the coccyx of a bedridden patient is red. The...

The nurse finds that the skin over the coccyx of a bedridden patient is red. The skin is intact. How will the nurse document this finding?

A.

Stage III pressure ulcer

B.

Stage II pressure ulcer

C.

Stage IV pressure ulcer

D.

Stage I pressure ulcer

2. What technique will be used to assess skin temperature?

A.

warm hands by rubbing them together then use finger tips.

B.

Use the fingertips in a rotary motion

C.

Use the palms of the hands on both arms at the same time

D.

The examiner will use the backs of his/her hands

3. Which skin color changes may indicate systemic illness?

A.

cherry angiomas, papules, and wheals

B.

Pallor, jaundice, or cyanosis

C.

mongolian spot, and milia

D.

Rubor and eccymosis

4. Which of the following are normal assessment findings when examining the nail beds?

The nail surface is smooth and the nail base is firm to palpation

The angle of the nail base is greater than 160 degrees and the nail base is spongy to palpation.

Light skinned clients may have brown linear streaks on the nail beds

Dark skinned clients may have thickened nails with ridges.

5. What will the nurse include when teaching skin self-examination?

A.

Use 2 mirrors to examine the skin every 3 months

B.

Ask a family member to search all areas of the skin each month

C.

Examine skin once a month using the ABCDE rule

D.

Use the ABCDE rule to examine the skin everyday after taking a shower

6. The nurse is providing education on the use of indoor tanning booths. What will be included in the education?

A.

Indoor tanning prior to vacationing provides protection from sun exposure equal to an SPF of 15.

B.

Indoor UV radiation carries less risk of skin cancer than direct sun exposure

C.

Exposure to UV radiation from indoor tanning does not increase the risk of squamous cell or basal cell cancer.

D.

Exposure to UV radiation from indoor tanning devices increases the risk for melanoma.

7. What technique will the nurse use to assess the client's hair? (Select all that apply.)

A.

Separate the hair into sections and lift it, observing the scalp.

B.

Note hair distribution on palms of hands and soles of feet

C.

Inspect hair for color, texture and distribution

D.

Palpate the skull for infestations

8. When obtaining health history information concerning the skin, which information will the nurse inquire about regarding any changes in moles?

A.

itching

B.

color

C.

excessive dryness

D.

shape

E.

bleeding

F.

tenderness

G.

pallor

H.

size

Expert Solution

1.The nurse finds that the skin over the coccyx of a bedridden patient is red. The skin is intact. How will the nurse document this finding?

Answer: Option D. Stage I pressure ulcer. As the skin is intact on the patient and nonblanchable redness of a localized area, usually over a bony prominenc in this case a coccyx

2. What technique will be used to assess skin temperature?

Answer: Option D.The examiner will use the backs of his/her hands. The use the dorsal surface (back side) of the hand because the skin is thinner there than on the palms

3. Which skin color changes may indicate systemic illness?

Answer: Option A.cherry angiomas, papules, and wheals. The presence of Cherry angiomas aong with papules and wheals in indicative of systemic dieases/ illnesss and may be a sign of internal malignancy state.

4. Which of the following are normal assessment findings when examining the nail beds?

Answer: Option A. The nail surface is smooth and the nail base is firm to palpation. This is conisdered healthy and normal nail beds while other are unexpected and indicates futher assesment to check for related illness.

5. What will the nurse include when teaching skin self-examination?

Answer: Option C. Examine skin once a month using the ABCDE rule. IN the ABCDE test the skin is checke for Asymmetry, Border irregularity, Color which is not uniform, Diameter greater than 6 mm and Evolving size, shape or color.

6. The nurse is providing education on the use of indoor tanning booths. What will be included in the education?

Answer: Option D. Exposure to UV radiation from indoor tanning devices increases the risk for melanoma. Exposure to artificial tanning has high risk of skin cancer or melanoma development.

7. What technique will the nurse use to assess the client's hair? (Select all that apply.)

Answer: Option A and C apply.

Option A. Separate the hair into sections and lift it, observing the scalp.

Option C. Inspect hair for color, texture and distribution

8. When obtaining health history information concerning the skin, which information will the nurse inquire about regarding any changes in moles?

Answer: Multiple Option apply for chnages in moles which include

Answer: Option B.color , Option D. shape and Option H.Size

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Nightingale answered 1 year ago

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