The nursing student performs a skin assessment on a 85-year-old client. Which finding is most concerning?
Skin remains red on the coccyx when pressed.
Dry scaly skin on the lower extremities.
Decreased tenting when assessing skin turgor.
Skin tags on neck line.
The Correct Answer is A
A. Skin remains red on the coccyx when pressed: Persistent redness that does not blanch under pressure is an early sign of tissue ischemia and potential pressure injury. In older adults, fragile skin and reduced subcutaneous tissue increase susceptibility to breakdown over bony prominences like the coccyx. Immediate intervention is required to relieve pressure, prevent ulceration, and preserve tissue integrity.
B. Dry scaly skin on the lower extremities: Xerosis, or dry, scaly skin, is common in older adults due to decreased sebaceous and sweat gland activity. While it requires routine moisturizing and monitoring, it does not pose an immediate threat to tissue viability or indicate acute injury, and thus is less concerning than non-blanching erythema.
C. Decreased tenting when assessing skin turgor: Decreased tenting suggests normal elasticity and adequate hydration, as opposed to tenting which indicates dehydration. This finding is typical in healthy skin and does not indicate acute risk for pressure injuries or compromised tissue perfusion.
D. Skin tags on neck line: Skin tags (acrochordons) are benign, soft growths associated with aging or friction in skin folds. They are not indicative of acute pathology, tissue ischemia, or imminent risk, making them a low-priority finding in comparison to non-blanching erythema over a bony prominence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Calculation:
The question asks for the volume of acetaminophen to administer in mL.
- Identify the ordered dose and available concentration
Ordered Dose: 320 mg
Available: 160 mg/5 mL
- Calculate the volume to administer
Volume (mL) = (Ordered Dose ÷ Available Dose) × Quantity
Volume = (320 ÷ 160) × 5
Volume = 2 × 5
= 10 mL
Correct Answer is C
Explanation
A. Turn and reposition every 2 hours: Repositioning every 2 hours is a standard evidence-based intervention to prevent pressure injuries. Frequent repositioning relieves sustained pressure over bony prominences, improves tissue perfusion, and reduces the risk of skin breakdown.
B. Completing personal hygiene and apply skin barrier products: Maintaining skin hygiene and using moisture barrier creams protects skin from irritants such as urine, feces, and sweat. These measures help preserve skin integrity, reduce maceration, and prevent breakdown, making them appropriate preventive interventions.
C. Reposition the patient every 8 hours: Repositioning only every 8 hours is inadequate for pressure injury prevention. Prolonged pressure beyond 2–3 hours can compromise capillary blood flow, leading to tissue ischemia and increased risk of skin breakdown. This intervention does not align with current best practices and should be questioned.
D. Cushion vulnerable parts of the body and redistribute body weight: Using pillows, foam pads, or specialized mattresses to offload pressure on bony prominences is a recommended intervention. Redistributing weight reduces localized pressure, improves circulation, and minimizes the risk of developing pressure injuries.
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