The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. Which is the best approach to making this assessment?

Use a fluorescent light source to assess the skin.

Inspect the skin only if the Braden score indicates a risk.

Avoid touching the skin during inspection.

Look for skin color that is darker than surrounding areas.

Answer and Explanation

The Correct Answer is D

Choice A reason: Using a fluorescent light source may not adequately reveal Stage I pressure ulcers in dark skin, as color changes are subtle. Natural or halogen light is preferred to detect darkening or erythema. Fluorescent light can distort pigmentation, reducing accuracy, per dermatological assessment techniques.

Choice B reason: Inspecting skin only if the Braden score indicates risk may miss early Stage I ulcers, which present as non-blanchable darkening in dark skin. Routine inspection is essential, as Braden scores predict risk but do not confirm ulcers, potentially delaying intervention, per pressure injury protocols.

Choice C reason: Avoiding touching the skin during inspection is inappropriate, as palpation detects warmth, induration, or non-blanching, key for Stage I ulcers in dark skin. Tactile assessment complements visual inspection, ensuring accurate identification of early tissue damage, per comprehensive skin assessment guidelines.

Choice D reason: Looking for skin darker than surrounding areas is the best approach for Stage I pressure ulcers in dark skin, as they present as non-blanchable hyperpigmentation rather than redness. This visual change indicates early tissue damage, guiding timely intervention to prevent progression, per pressure ulcer staging standards.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Bradycardia (pulse <60 bpm) is unlikely, as fever, infection, and pain increase sympathetic nervous system activity, elevating heart rate. Infection triggers cytokine release, and pain stimulates adrenaline, both increasing cardiac output to meet metabolic demands. Bradycardia would contradict the physiological stress response, making this incorrect for this scenario.

Choice B reason: Tachycardia (pulse >100 bpm) is likely due to fever, infection, and pain activating the sympathetic nervous system. Fever increases metabolic rate, infection induces inflammatory cytokines, and pain releases adrenaline, all elevating heart rate to enhance oxygen delivery. This physiological response matches the client’s condition, making tachycardia the correct pulse type.

Choice C reason: Dysrhythmia involves irregular heart rhythms, like atrial fibrillation, not directly caused by fever, infection, or pain. These conditions increase heart rate via sympathetic stimulation, not necessarily rhythm irregularity. Dysrhythmias require specific cardiac issues, unlike the expected tachycardia from systemic stress, making this incorrect for the client’s presentation.

Choice D reason: Bigeminal pulse (paired beats) indicates a specific arrhythmia, not typically caused by fever, infection, or pain. These conditions elevate heart rate through sympathetic activation and cytokine release, leading to tachycardia, not patterned beats. Bigeminal rhythms require cardiac-specific issues, making this an unlikely pulse type in this systemic stress scenario.

A. Cyanosis B. Wheezing C. Decreased level of consciousness D. Frequent coughing

Correct Answer is C

Explanation

Choice A reason: Cyanosis, a bluish skin discoloration, indicates hypoxemia in COPD due to impaired gas exchange in damaged alveoli. While concerning, it is a common chronic symptom and not immediately life-threatening unless rapidly worsening. Decreased level of consciousness signals severe hypoxia affecting cerebral oxygenation, requiring urgent reporting over stable cyanosis.

Choice B reason: Wheezing results from airway obstruction in COPD, caused by bronchoconstriction and mucus accumulation, reducing airflow. It’s a chronic symptom managed with bronchodilators. While important, it does not indicate acute decompensation like decreased consciousness, which reflects critical cerebral hypoxia and requires immediate intervention to prevent brain damage.

Choice C reason: Decreased level of consciousness indicates severe hypoxia in COPD, as low oxygen saturation impairs cerebral function. Brain cells require constant oxygen for ATP production via aerobic metabolism. Hypoxia reduces cerebral perfusion, causing confusion or unresponsiveness, signaling a life-threatening emergency. This finding warrants immediate reporting to address acute respiratory failure.

Choice D reason: Frequent coughing in COPD results from mucus production and airway irritation, a common chronic symptom. It aids in clearing secretions but does not indicate acute decompensation. Unlike decreased consciousness, which reflects severe cerebral hypoxia, coughing is less urgent and managed with expectorants or airway clearance techniques, not immediate reporting.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. Which is the best approach to making this assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Correct Answer is B

Explanation

The nurse provides care for a client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Correct Answer is C

Explanation

A nurse measures a patient’s 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse do with the information?

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is affected? being tested?

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client’s blood pressure is 90/50 mmHg. What is the name for this condition?

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

A nurse is teaching a client at risk for melanoma about what to look out for when checking the skin. The nurse determines that the teaching was successful based on which client statement(s)? (Select all that apply)

Before administering a cleansing enema to an 80-year-old patient, the patient says, “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?