The nurse completes a skin assessment on a group of clients. Which client would be of greatest concern?
An older adult with fragile skin and a new dark red bruise
A child with fine vellus hair and no signs of rash
A pregnant client with increased sweating and mild skin darkening
An adolescent with mild acne and oily skin
The Correct Answer is A
A. An older adult with fragile skin and a new dark red bruise is of greatest concern. Older adults often have thinner, more fragile skin due to aging, making them more susceptible to skin tears, bruising, and pressure injuries. A new dark red bruise may indicate trauma, potential falls, or even elder abuse, which requires immediate assessment and follow-up. Monitoring for hematomas, skin integrity, and underlying causes is critical.
B. A child with fine vellus hair and no signs of rash represents a normal skin finding in children. Fine, soft vellus hair is expected, and without any rashes, lesions, or other abnormalities, there is no immediate concern.
C. A pregnant client with increased sweating and mild skin darkening is experiencing normal physiological changes of pregnancy, such as hyperpigmentation (linea nigra, melasma) and increased diaphoresis. These are typically benign and do not indicate urgent pathology.
D. An adolescent with mild acne and oily skin is experiencing common hormonal skin changes of puberty. While acne management may be appropriate, it is not an immediate concern for acute skin compromise or systemic issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for Correct Answer:
When assessing the pupillary light reflex, the nurse shines a light into one eye and observes direct response, that is the illuminated pupil constricts, and consensual response where the opposite pupil also constricts. The normal reaction to light is pupillary constriction, not dilation.
Rationale for Incorrect Options:
Indirect: This is not the correct terminology used in pupillary light reflex assessment. The correct term is direct response.
Consensual: This refers to the opposite eye’s response, not the illuminated eye. The first blank refers to the response of the eye receiving the light.
Dilation: Pupils dilate in darkness, not in response to light. Light causes constriction.
Accommodation: This refers to pupil constriction when shifting focus from far to near objects, not the light reflex.
Correct Answer is ["A","C","E","F"]
Explanation
A. The client’s blood pressure improved from 90/56 (hypotension) to 120/80 (normal range). Hypotension can indicate systemic infection or early sepsis. A return to normal blood pressure suggests improved circulation and response to treatment. This is a significant sign of stabilization.
B. Oxygen saturation remained unchanged at 95% on room air. While this is within acceptable range, there was no improvement. It indicates stability but does not demonstrate change. Therefore, it does not reflect measurable improvement.
C. The respiratory rate decreased from 19 to 18 breaths per minute. Although both values are within normal limits (12–20 breaths per minute), infection and fever may cause mild tachypnea. The slight decrease reflects improved physiologic stress and stabilization.
D. The heart rate decreased from 110 (tachycardia) to 98 (within normal range). Fever and infection commonly cause tachycardia. A decrease toward normal indicates that the body is no longer under the same level of stress from infection. This is an important sign of recovery.
E. The temperature decreased from 102.3°F (39°C), which is clearly febrile, to 99.9°F (37.7°C), which is near normal. Fever is a hallmark sign of infection. A reduction in temperature is one of the strongest indicators that treatment is effective.
F. Pain improved from 6/10 to 2/10. Lower back pain can indicate kidney involvement (such as pyelonephritis). Decreasing pain suggests reduced inflammation and infection. Pain improvement is an important clinical indicator of recovery.
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