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 True
Explanation
Choice A reason: A friction rub is a scratching or squeaking sound from inflamed pleural surfaces, persisting throughout the respiratory cycle and unaffected by coughing, as pleural inflammation (e.g., pleurisy) causes consistent friction. Accurate recognition ensures proper reporting, guiding diagnosis and treatment of underlying conditions like pneumonia or pulmonary embolism in respiratory assessments.
Choice B reason: Assuming false is incorrect, as friction rubs indeed persist through the respiratory cycle without clearing by coughing, unlike rhonchi. Misidentifying this risks misdiagnosis, potentially overlooking pleural inflammation needing anti-inflammatory or antibiotic therapy, delaying treatment and increasing complications in patients with respiratory conditions causing friction rubs.
Correct Answer is C
Explanation
Choice A reason: Asking about the time assesses temporal orientation, a component of cognitive function, but is less comprehensive than date recall. Time awareness can vary due to environmental factors or confusion, making it less reliable for evaluating overall orientation in older adults, who may have memory deficits.
Choice B reason: Asking if the patient can stand up tests physical ability, not cognitive orientation. Orientation assessment focuses on awareness of time, place, and person, critical for detecting delirium or dementia. Physical tests are irrelevant to mental status evaluation, making this an inappropriate question.
Choice C reason: Asking for the date evaluates orientation to time, a key component of cognitive assessment in older adults. It tests memory and awareness, crucial for detecting cognitive impairments like dementia. This question is specific, measurable, and aligns with standard mental status examinations, making it the most appropriate.
Choice D reason: Asking about feelings assesses emotional state, not orientation. While relevant for overall health, it does not evaluate cognitive awareness of time, place, or person. Orientation questions target memory and perception, critical for neurological assessment, rendering this choice less relevant for the task.
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