NSG 121 - Health Assessment
Exam 2
Question:
What is clean-contaminated wound?
Answer:
"Clean-contaminated wounds are those that are made under sterile conditions", like surgical incisions, but involve the respiratory, genitourinary, and gastrointestinal tracts. "A bowel resection", which is surgical removal of a portion of the small or large intestine, is an example of a clean- contaminated wound
Question:
What is burn classification?
Answer:
The factors used to classify burns are depth of tissue destruction and percentage of total body surface area affected. Vascular assessment of the burned area is necessary to determine depth of tissue destruction. "The nurse attempts to blanch the burned area by applying pressure with a sterile, cotton-tipped applicator, and then observes capillary refill" when the pressure is released.
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Question:
What would be included in the documentation of a pressure injury?
Answer:
- Documentation of a pressure injury should include the size in depth and
"diameter, color and texture of the tissue, amount, color, consistency, and odor of any exudate (drainage)," condition of surrounding tissue, location using appropriate landmarks, and any associated pain.
Question:
ABCDEs melanoma
Answer:
"asymmetry; border color; diameter; and evolution"
Question:
A patient client is using the sternocleidomastoid and the trapezius muscles for breathing what action by the nurse?
Answer:
- The nurse should immediately recognize that the client is using accessory
muscles for breathing and should "complete a full respiratory assessment." After obtaining this information, the next step would be to report the information found to the health care provider.
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Question:
When assessing a 6-month-old client's head and neck what finding would you document?
Answer:
- "You should expect the sutures of the cranium to be soft and loose at this
age." The sutures close approximately at age 12 to 18 months of age.
Question:
When assessing the mouth of an older adult client what finding would you report?
Answer:
- "The nurse should report a lesion that changes or persists because a biopsy
should be done to rule out oral cancer
Question:
Risk factors of cancer of the neck
Answer:
- Risk factors for cancer of the neck include male gender over the age of 50.
Tobacco use and "alcohol consumption"
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