The nurse is aware that which patients are at risk for a skin alteration?
The patient who had numbness in the right arm that resolved several hours ago.
A patient who has been newly diagnosed with diabetes.
A patient who has had vomiting and diarrhea for several days and lost 12 pounds.
The patient who has paralysis and is unable to move in the bed.
A roofer who spends a lot of time outdoors.
Correct Answer : B,C,D,E
Choice A rationale
While temporary numbness could indicate transient nerve compression, which might rarely predispose to minor skin issues if prolonged or repetitive, it typically resolves without lasting dermatological compromise. Sustained pressure or impaired sensation are the primary risk factors for skin breakdown. This transient event is less likely to lead to a significant skin alteration compared to chronic conditions affecting tissue integrity.
Choice B rationale
Diabetes mellitus impairs microcirculation and peripheral neuropathy, leading to decreased sensation and reduced blood flow to tissues. This compromises the skin's ability to heal and resist infection. Hyperglycemia also weakens collagen and elastin, making the skin more fragile and susceptible to breakdown and delayed wound healing.
Choice C rationale
Significant fluid and electrolyte imbalances due to vomiting and diarrhea, coupled with substantial weight loss, lead to dehydration and malnutrition. Dehydration reduces skin turgor and elasticity, making it more prone to tearing. Malnutrition, particularly protein deficiency, impairs tissue repair and maintenance, increasing susceptibility to skin breakdown.
Choice D rationale
Paralysis prevents independent repositioning, leading to prolonged pressure on bony prominences. This sustained pressure compromises capillary blood flow, resulting in tissue ischemia and necrosis. Without the ability to shift weight, the skin's protective mechanisms are overwhelmed, significantly increasing the risk for pressure injury development.
Choice E rationale
Chronic exposure to ultraviolet (UV) radiation from sunlight, experienced by roofers, causes cumulative damage to dermal collagen and elastin fibers, leading to photoaging. This also increases the risk of basal cell carcinoma, squamous cell carcinoma, and melanoma, which are significant skin alterations including premalignant and malignant lesions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Peripheral edema, characterized by swelling in the extremities due to fluid retention, is not a typical manifestation of myasthenia gravis. Myasthenia gravis is an autoimmune disorder primarily affecting neuromuscular transmission, leading to muscle weakness rather than fluid imbalances.
Choice B rationale
Drooping eyelids, also known as ptosis, is a very common and often early symptom of myasthenia gravis. It results from weakness of the levator palpebrae superioris muscle due to impaired acetylcholine receptor function at the neuromuscular junction, a hallmark of the disease.
Choice C rationale
Myasthenia gravis primarily affects voluntary muscles and does not typically cause loss of cognitive function. Cognitive abilities, such as memory, attention, and problem-solving, are generally preserved in patients with this condition, distinguishing it from neurological disorders that directly impact the brain.
Choice D rationale
Fluctuations in heart rate are not a characteristic finding in myasthenia gravis. While severe generalized muscle weakness can indirectly impact respiratory and cardiovascular function, the disease itself does not directly cause dysregulation of heart rate. Heart rate is typically regulated by the autonomic nervous system.
Correct Answer is A
Explanation
Choice A rationale
Bright red blood in the urine, especially in large amounts or clots, after a cystoscopy is an abnormal finding. While some pink-tinged urine is expected, significant bright red bleeding can indicate hemorrhage or bladder wall injury requiring immediate medical intervention to prevent complications.
Choice B rationale
Urinary frequency is a common and expected finding after a cystoscopy due to irritation of the bladder mucosa from the procedure. This typically resolves within a day or two as the bladder recovers from instrumentation.
Choice C rationale
Pink-tinged urine is considered a normal and expected finding after a cystoscopy. The procedure involves instrumentation of the urethra and bladder, which can cause minor trauma to the mucosal lining, leading to a small amount of blood in the urine.
Choice D rationale
Burning on urination, also known as dysuria, is a common and expected sensation after a cystoscopy due to irritation and inflammation of the urethra and bladder from the scope. This discomfort usually subsides within 24 to 48 hours.
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