A Nurse Practitioner working in a dermatology clinic finds an open lesion on his patient. When assessing this lesion, what is an important assessment parameter?
When assessing this lesion, what is an important assessment parameter?
A) Assess for wound edges, including overmining.
B) Assess for size, including surrounding erythema.
C) Assess for appropriate dressing.
D) Assess for application of appropriate medication.
Ans: B
Feedback: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. This assessment should address the following issues: wound bed: inspect for necrotic and granulation tissue, epithelium, exudate, color, and odor; wound edges and margins: observe for undermining (ie, extension of the wound under the surface skin), and evaluate for condition; wound size: measure in millimeters or centimeters, as appropriate, to determine diameter and depth of the wound and surrounding erythema; surrounding skin: assess for color, suppleness, and moisture. At this point an appropriate dressing has not been determined, nor has the correct medication been ordered.
You might also like to view...
The nurse performs an assessment on four hospitalized pediatric clients. After reviewing each client's admitting diagnosis, which pediatric client may have an enlarged spleen?
1. 14-year-old admitted with acute gastroenteritis. 2. 17-year-old admitted with an acute exacerbation of asthma. 3. 11-year-old admitted with an umbilical hernia. 4. 9-year-old admitted with a sickle cell crisis.
The client has an elevated temperature. Which statement is the most clinically appropriate for the nurse to use when documenting this finding in the medical record?
1. The client is fever. 2. The client is febrile. 3. The client is hyperpyrexia. 4. The client is hyperthermia.
Clients using The Dietary Approaches to Stop Hypertension (DASH) diet have been shown to have a decreased risk of coronary heart disease, stroke, and overall mortality
When assisting the client on the DASH diet to make food selections, the nurse should be sure to include: 1. 5 servings of fruit, 3 servings of vegetables, and 2 servings of low-fat dairy products daily. 2. 3 servings of fruits, 5 servings of vegetables, and 3 servings of dairy products daily. 3. 4 servings of fruits and vegetables and 1 serving of dairy products daily. 4. 5 servings of fruits, vegetables, and dairy products daily.
In searching a database, a controlled vocabulary is
a. a list of forbidden words that cannot be used as search terms b. a series of keywords that must be entered in a specific order c. proprietary terms that can only be used when searching one particular database d. a standardized, hierarchical list of terms that represent major subjects and conditions