A nursing student is performing a skin assessment on admission in a long term care facility. Which finding is of most concern?

Toenails that are thickened and yellow.

Stretch marks noted across the abdomen and buttocks.

An irregular border noted on a black mole on the scalp.

Dry skin present on the elbows and knees.

Answer and Explanation

The Correct Answer is C

A. Toenails that are thickened and yellow: Thickened, yellow toenails are commonly associated with onychomycosis or age-related changes. While this may require treatment for fungal infection, it does not pose an immediate threat to overall health and is generally considered a chronic, manageable condition in long-term care.

B. Stretch marks noted across the abdomen and buttocks: Stretch marks (striae) are typically related to prior weight changes, pregnancy, or corticosteroid use. They are not indicative of an acute or potentially life-threatening condition and are primarily a cosmetic or chronic skin change.

C. An irregular border noted on a black mole on the scalp: A mole with an irregular border, especially if it is dark in color and located in a less visible area like the scalp, raises concern for malignant melanoma. Early identification and referral for dermatologic evaluation are crucial, as melanoma can metastasize and become life-threatening if not treated promptly.

D. Dry skin present on the elbows and knees: Dry skin in older adults is a common finding due to reduced sebaceous activity and environmental factors. While it may require moisturizing and education on skin care, it does not represent an immediate health threat compared with suspicious pigmented lesions.

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Correct Answer is B

Explanation

A. Annual pap smear: Routine Pap smears are generally not recommended for women older than 65 who have had adequate prior screening and are not at high risk for cervical cancer. Continuing Pap smears in this age group offers minimal benefit for disease prevention, making it a lower priority compared with vaccinations that prevent life-threatening infections.

B. Pneumococcal immunization: Pneumococcal vaccination is highly recommended for adults aged 65 and older because aging increases susceptibility to pneumococcal infections, including pneumonia, bacteremia, and meningitis. Immunization significantly reduces morbidity and mortality in this population, making it the highest priority in older adults.

C. Annual mammogram: While mammography is important for early detection of breast cancer, current guidelines typically recommend individualized decision-making for women aged 70 and older, especially if life expectancy is limited or comorbidities exist. Vaccinations provide broader population-level protection against serious infections and thus take precedence.

D. Human papilloma virus (HPV) immunization: HPV vaccination is primarily targeted toward adolescents and young adults up to age 26, with some recommendations extending to 45. For adults over 70, HPV immunization does not provide meaningful protection, as exposure risk is low and immune response may be diminished, making it irrelevant for this age group.

A. Capillary refill is less than 2 seconds B. Fecal Incontinence C. A raised red rash on the right shin D. Ate two thirds of breakfast

Correct Answer is B

Explanation

A. Capillary refill is less than 2 seconds: A rapid capillary refill indicates good peripheral perfusion, which reduces the risk of tissue ischemia and pressure injury. This finding reflects normal circulatory function and is not a risk factor for PI formation.

B. Fecal incontinence: Fecal incontinence increases the risk of pressure injury because moisture, enzymes, and bacteria from stool can macerate the skin, impairing its integrity. Combined with immobility or pressure over bony prominences, incontinence significantly contributes to skin breakdown and PI development.

C. A raised red rash on the right shin: While a rash may indicate irritation or dermatitis, it is a localized skin condition and does not automatically reflect a generalized risk for pressure injuries. Pressure injuries are primarily associated with sustained pressure, friction, shear, and moisture over bony prominences.

D. Ate two thirds of breakfast: Nutritional intake is important for skin integrity, but consuming most of a meal indicates adequate intake rather than a risk factor. Malnutrition or insufficient caloric/protein intake would increase PI risk, but this observation alone does not.

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A nursing student is performing a skin assessment on admission in a long term care facility. Which finding is of most concern?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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