HESI Case Study: Integumentary Assessment – Flashcards
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What follow up assessment should the nurse perform after observing the facial flushing?
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Ask about any feelings of anxiety
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The nurse observes that there are numerous blackheads around Mandi's chin and nose. What action should the nurse taken response to this finding?
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Note any pustules or nodules
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The nurse attempts to question Mandi about her vomiting. Mandi refuses to talk about the vomiting episodes that occurred earlier in the day, stating that she must have ate something bad the night before dinner. However, she seems open to talking about other things, so the nurse continues with the client interview, focusing on the appearance of her skin, hair, and nails.
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How often do you use a tanning booth?
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Mandi also points out a small (1mm) smooth, slightly raised bright res dot on her abdomen and asks the nurse to examine that the spot as well. How should the nurse proceed?
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Offer assurance that this lesion is not an abnormal finding
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The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?
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Document the location of the bruises and petechiae
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To gather data related to the frequency of abuse by Mandi's boyfriend, what action should the nurse take first?
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Provide a calendar for the client to mark the dates when any violent and abusive behavior by her boyfriend occured
