HESI Case Study: Integumentary Assessment – Flashcards

question
What follow up assessment should the nurse perform after observing the facial flushing?
answer
Ask about any feelings of anxiety
question
The nurse observes that there are numerous blackheads around Mandi's chin and nose. What action should the nurse taken response to this finding?
answer
Note any pustules or nodules
question
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.
answer
How often do you use a tanning booth?
question
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?
answer
Offer assurance that this lesion is not an abnormal finding
question
The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?
answer
Document the location of the bruises and petechiae
question
To gather data related to the frequency of abuse by Mandi's boyfriend, what action should the nurse take first?
answer
Provide a calendar for the client to mark the dates when any violent and abusive behavior by her boyfriend occured
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question
What follow up assessment should the nurse perform after observing the facial flushing?
answer
Ask about any feelings of anxiety
question
The nurse observes that there are numerous blackheads around Mandi's chin and nose. What action should the nurse taken response to this finding?
answer
Note any pustules or nodules
question
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.
answer
How often do you use a tanning booth?
question
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?
answer
Offer assurance that this lesion is not an abnormal finding
question
The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?
answer
Document the location of the bruises and petechiae
question
To gather data related to the frequency of abuse by Mandi's boyfriend, what action should the nurse take first?
answer
Provide a calendar for the client to mark the dates when any violent and abusive behavior by her boyfriend occured