What is an unexpected finding for the integumentary system assessment?

Skin is warm and dry.

IV site is clear and no drainage.

Stage 1 pressure injury to right heel.

Skin color is consistent with person’s racial heritage.

Answer and Explanation

The Correct Answer is C

Choice A reason: Warm, dry skin is a normal finding, reflecting adequate circulation and hydration, expected in healthy integumentary assessments. It’s not concerning unless accompanied by fever or dehydration. Assuming this is unexpected risks overcomplicating care, diverting focus from actual abnormalities like pressure injuries requiring intervention in skin assessments.

Choice B reason: A clear IV site without drainage is expected, indicating no infection or infiltration. Unexpected findings involve redness or leakage. Assuming this is abnormal risks unnecessary interventions, diverting attention from true integumentary issues like pressure injuries, critical for preventing complications in patients with prolonged IV therapy.

Choice C reason: A stage 1 pressure injury, with non-blanchable erythema, is an unexpected and concerning finding, indicating early tissue damage requiring intervention like repositioning or pressure relief. Unlike normal skin findings, this signals risk of progression, necessitating prompt documentation and care to prevent worsening ulcers in vulnerable patients.

Choice D reason: Skin color consistent with racial heritage is expected and normal, reflecting genetic pigmentation. Unexpected findings involve changes like pallor or cyanosis. Assuming this is abnormal risks misinterpretation, neglecting actual integumentary issues like pressure injuries, critical for accurate assessment and timely intervention in skin health.

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Correct Answer is B

Explanation

Choice A reason: Limited ability to reposition is a major risk factor for pressure injuries, as immobility increases pressure on bony prominences, reducing blood flow and causing tissue ischemia. This leads to skin breakdown, particularly in bedridden patients, making it a critical factor in pressure ulcer development.

Choice B reason: Requiring stand-by assistance for activities of daily living (ADLs) indicates some mobility, as the patient can perform tasks with supervision. This does not inherently increase pressure injury risk, unlike immobility or moisture, making it the least relevant risk factor among the choices.

Choice C reason: Poor nutritional state is a risk factor for pressure injuries, as malnutrition impairs skin integrity and wound healing. Deficiencies in protein or vitamins reduce tissue resilience, increasing susceptibility to pressure-induced damage, particularly in elderly or debilitated patients.

Choice D reason: Moisture from incontinence, wound drainage, or perspiration softens skin, increasing friction and shear forces, which heighten pressure injury risk. It compromises skin barrier function, promoting maceration and ulceration, making it a significant contributor to pressure ulcer formation.

A. Full thickness skin loss with visible bone. B. Intact skin with localized erythema. C. Full thickness skin loss with visible adipose tissue. D. Partial-thickness skin loss with red tissue in wound bed.

Correct Answer is B

Explanation

Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.

Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.

Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.

Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.

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What is an unexpected finding for the integumentary system assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is not a risk factor for pressure injuries?

Correct Answer is B

Explanation

In a patient’s chart, it notes that the patient has a stage 1 pressure injury. Which of the following findings would you expect to see when you do your assessment?

Correct Answer is B

Explanation

As you review an elderly patient’s chart, you see osteoporosis listed as a diagnosis. Which of the following spinal deformities should the nurse expect to see during the nurse’s assessment?

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Which of the below items are expected variations in an older adult?

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Select the closed-ended question below.

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