Theory midterm #2

•A nurse is teaching a patient how to perform a skin self-examination using the ABCDEs of melanoma detection. Which finding should the nurse instruct the patient to report to their healthcare provider?

•A mole that has recently changed in shape, developed irregular borders, and contains several shades of brown and black.

•A nurse is educating a patient who enjoys gardening and frequently spends time outdoors during midday hours. Which statement by the patient indicates a need for further teaching about reducing the risk of melanoma?

•"I only need to apply sunscreen once in the morning, even if I am outside all day."

•A nurse is assessing a patient who has limited mobility, frequently experiences urinary incontinence, and has poor nutritional intake. The patient's Braden Scale score is 13. Which interpretation of this assessment is most appropriate?

•The patient has moderate risk for pressure injury development and requires preventive nursing interventions.

•A nurse is assessing a patient who has a pressure injury on the right heel. The wound has full-thickness skin and tissue loss with visible tendon and muscle. The nurse also observes thick, yellow-green drainage. How should the nurse document these findings?

•Stage 4 pressure injury with purulent drainage.

•A nurse is assessing the skin turgor of an older adult patient who may be dehydrated. Which technique is most appropriate for obtaining an accurate assessment?

•Gently pinch the skin over the anterior chest, below the midclavicular area, and observe how quickly it returns to its normal position.

A nurse is performing a musculoskeletal assessment on a patient who recently had a cast removed from the right leg. Which assessment finding should the nurse recognize as abnormal and requiring further evaluation?

The right calf is noticeably smaller than the left calf.

•A nurse is caring for a patient who fell and injured their left forearm. The patient reports severe pain, and the nurse observes swelling and an abnormal alignment of the arm. Which nursing action is most appropriate?

•Immobilize the arm in its current position and keep the patient still and comfortable.

•A nurse is performing a comprehensive musculoskeletal assessment on an adult patient. Which nursing action demonstrates the appropriate approach to assessing the musculoskeletal system?

•Assess posture, gait, balance, coordination, extremities, joint range of motion, muscle strength, and functional ability.

•A nurse is assessing a patient who reports persistent pain in the left shoulder. The nurse observes no swelling, redness, or deformity. Which nursing action is most appropriate?

Assess the pain's location, intensity, quality, duration, and aggravating or relieving factors.

•A nurse is teaching a patient about dietary choices to help prevent osteoporosis. Which statement by the patient indicates an understanding of the teaching?

•"I should limit excessive caffeine consumption because caffeine can increase the amount of calcium lost through urine."

If a client consumed 8 ounces of juice, the RN should document _____ mLs on the intake record.

240

A nurse is assessing a patient with chronic kidney disease. Which finding may result from the kidneys' decreased ability to produce erythropoietin?

Decreased red blood cell production, resulting in anemia.

A nurse is assessing the urine output of a hospitalized patient. Which finding requires immediate notification of the healthcare provider?

Cola-colored urine in a patient who recently sustained a severe muscle injury.

A nurse is monitoring the urinary output of a hospitalized adult patient. Which assessment finding is most concerning and requires prompt nursing intervention?

The patient has produced 90 mL of urine over the past 6 hours.

A nurse is teaching a patient about the structures of the urinary system and how urine is eliminated from the body. Which statement by the patient indicates a correct understanding?

“Urine is produced by the kidneys, travels through the ureters to the bladder, and exits the body through the urethra."

A nurse is assessing a patient who reports changes in urinary habits. Which assessment finding should alert the nurse to a possible urinary tract infection (UTI)?

Cloudy urine accompanied by burning during urination and increased urinary frequency.