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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Percussion involves tapping to assess underlying structures, commonly used for lung or abdominal assessments. In breast assessment, it is not relevant, as it cannot evaluate tissue density or detect masses. Breast examination relies on visual inspection and palpation to identify abnormalities like lumps or skin changes, making percussion inappropriate.
Choice B reason: Inspection is a critical technique in breast assessment, involving visual examination for asymmetry, skin changes, nipple discharge, or dimpling. It precedes palpation to identify visible abnormalities. This method is non-invasive and essential for detecting early signs of breast conditions, such as cancer, aligning with standard clinical protocols for thorough evaluation.
Choice C reason: Doppler ultrasound assesses blood flow, often used in vascular or fetal monitoring, but is not standard for breast assessment. Breast examination uses inspection and palpation, with imaging like mammography for deeper evaluation. Doppler’s role in breast care is limited to specialized diagnostics, not routine physical assessments, making it an incorrect choice.
Choice D reason: Sterile gloves are used for invasive procedures like wound care, not routine breast assessments, which require clean gloves for palpation. Inspection and palpation are primary techniques, and sterile conditions are unnecessary unless performing a biopsy. This choice does not align with standard breast examination practices.
Correct Answer is B
Explanation
Choice A reason: The left lower quadrant contains the sigmoid colon and parts of the small intestine, not the liver. Liver assessment involves palpation and percussion in the right upper quadrant, where it resides, making this choice incorrect for locating the liver anatomically.
Choice B reason: The liver is located in the right upper quadrant, beneath the diaphragm, extending slightly into the left upper quadrant. It is assessed via percussion and palpation in the RUQ to evaluate size or tenderness, making this the correct choice for liver localization.
Choice C reason: The left upper quadrant houses the stomach, spleen, and parts of the pancreas, not the liver’s primary location. While the liver’s left lobe extends slightly into the LUQ, its main mass is in the RUQ, making this choice incorrect.
Choice D reason: The right lower quadrant contains the appendix and cecum, not the liver. Liver assessment targets the right upper quadrant, where its bulk resides, making this choice incorrect for identifying the liver’s anatomical position during physical examination.
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