A nurse is assessing a patient's skin for temperature and moisture.
What is the most appropriate technique to use?
Percussion.
Inspection.
Auscultation.
Palpation.
The Correct Answer is D
Choice A rationale
Percussion involves tapping on the body surface to produce sounds that indicate the density of underlying tissues. While useful for assessing organs like the lungs or abdomen, it is not the primary technique for evaluating skin temperature and moisture.
Choice B rationale
Inspection involves visual observation of the skin for color, lesions, and general appearance. While it contributes to overall skin assessment, it does not directly evaluate temperature or moisture, which require tactile sensation.
Choice C rationale
Auscultation involves listening to internal body sounds, typically with a stethoscope. This technique is used for assessing heart, lung, and bowel sounds and is not applicable for evaluating skin temperature or moisture.
Choice D rationale
Palpation involves using touch to assess various characteristics of the body. Light palpation with the dorsal surface of the hand is the most sensitive method for detecting subtle changes in skin temperature due to the thinness of the skin and abundant thermoreceptors. Skin moisture is also directly assessed by touch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Palpating along the lumbar vertebral column primarily assesses for spinal tenderness or musculoskeletal issues, not specifically kidney inflammation. The kidneys are retroperitoneal organs, and direct palpation of the lumbar area might not elicit specific tenderness related to pyelonephritis, which involves renal parenchymal inflammation.
Choice B rationale
Striking a flat hand covering the costovertebral angle (CVA) elicits pain if the kidney capsule is inflamed, a classic sign of pyelonephritis. This maneuver, known as CVA tenderness, directly assesses for inflammation of the renal parenchyma or surrounding structures, which become sensitive to percussion with infection.
Choice C rationale
Pushing fingers upward into the two lowest intercostal spaces would primarily assess for liver or spleen enlargement, or tenderness related to the lower ribs, not directly for kidney tenderness. The kidneys are situated more posteriorly and superiorly, making this approach less effective for assessing pyelonephritis.
Choice D rationale
Percussing between the iliac crest and ribs at the midaxillary line targets the flank area but is not the most precise method for assessing kidney tenderness. While it's in the general vicinity, the CVA percussion directly overlies the kidney and is a more specific and sensitive maneuver for pyelonephritis.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Mobility is a critical subscale in the Braden Scale. It assesses the patient's ability to change and control body position independently. Impaired mobility significantly increases the risk of prolonged pressure on specific body areas, leading to tissue ischemia and subsequent pressure injury development.
Choice B rationale
Pain is not a direct subscale in the Braden Scale. While pain can indirectly affect mobility and activity levels, it is not one of the six core parameters used to quantify the risk of pressure injury development according to the established framework of the Braden Scale, which focuses on extrinsic and intrinsic factors affecting skin integrity.
Choice C rationale
Nutrition is a key subscale in the Braden Scale. It evaluates the patient's usual food intake pattern. Adequate nutrition, particularly protein and calories, is essential for maintaining tissue integrity and promoting wound healing. Malnutrition compromises skin resilience and repair mechanisms.
Choice D rationale
Sensory perception is a vital subscale in the Braden Scale. It measures the patient's ability to respond meaningfully to pressure-related discomfort. Patients with impaired sensory perception may not perceive pressure or pain, failing to shift their weight and thus increasing their risk for tissue damage.
Choice E rationale
Moisture is a crucial subscale in the Braden Scale. It assesses the degree to which skin is exposed to moisture, such as urine, feces, or perspiration. Prolonged exposure to moisture macerates the skin, making it more fragile and susceptible to breakdown from friction and shear forces.
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