vSIMS #1 Exam Questions With Solutions

vSIMS #1 Exam Questions With Solutions 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. Prealbumin 6 mg/dL c. Urine protein 60 mg/ 24 hours d. Albumin 5.2 g/dL - ANS b. Prealbumin 6 mg/dL Ms. Morrow asks "What is the Braden scale that you keep talking about?" What is the correct response by the nurse? a. This assessment will help me find out if you will be able to take care of yourself at home. b. It is a tool to determine whether or not you are at risk for falls. c. This tool will help me determine if you are at risk for developing pressure ulcers. d. It is a technique used to identify common problems in older adults. - ANS c. This tool will help me determine if you are at risk for developing pressure ulcers. 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. Surface of the abdomen c. Hair and scalp d. Groin e. Limbs - ANS a. Under the breasts d. Groin e. Limbs The nurse is completing a skin assessment of an older adult patient. Which finding would require immediate attention? a. Striae on the abdomen and thighs b. Reddened area on the patient's heel c. Small, flat macules on both shoulders d. A raised nevus on the back of the neck - ANS b. Reddened area on the patient's heel 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. Stage III Pressure ulcer b. Arterial ulcer c. Unstageable pressure ulcer d. Venous stasis ulcer - ANS d. Venous stasis ulcer 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. Install safety rails in your bathroom to help prevent falls. b. Watch for signs and symptoms of new ulcers. c. Participate in activities that require physical contact to promote circulation d. Wear support stockings to help prevent ulcers and heal existing ones e. Choose footwear that is nonskid with a low heel. - ANS b. Watch for signs and symptoms of new ulcers. d. Wear support stockings to help prevent ulcers and heal existing ones 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 let my nurse know if the wound gets bigger, starts to hurt more, or smells bad. c. My caregivers should follow the provider's instructions precisely when changing the dressing. d. I should keep the wound clean to prevent it from becoming infected. - ANS a. I can expect my wound to heal in 1 to 3 months. 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. Leg pain and brownish or blue skin discoloration b. Diminished pulses in the affected extremity c. Pallor in the lower extremity d. Dependent rubor - ANS a. Leg pain and brownish or blue skin discoloration 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. Green, leafy vegetables b. Cereals and fruits c. Meats, cheese, and beans d. Whole wheat bread and brown rice - ANS c. Meats, cheese, and beans 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. Distribution c. Length d. Lesions e. Amount - ANS a. Condition b. Distribution d. Lesions e. Amount 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. Observation of legs for color and unusual vein patterns b. Auscultation or palpation of peripheral pulses c. Comparison of one leg to another d. Measurement of leg circumference at different anatomical levels e. Palpation for warmth and tenderness - ANS a. Observation of legs for color and unusual vein patterns b. Auscultation or palpation of peripheral pulses c. Comparison of one leg to another e. Palpation for warmth and tenderness 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. Centimeter ruler b. Magnifying glass c. Measuring tape d. Goniometer e. Penlight - ANS a. Centimeter ruler b. Magnifying glass e. Penlight 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. When did it begin? b. Have you had any hair loss? c. How much does it bother you? d. What other symptoms