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 A

Explanation

Choice A reason: The epidermis is the most superficial skin layer, providing a protective barrier against pathogens and UV radiation. Composed of stratified squamous epithelium, it’s critical for skin integrity. Accurate identification guides wound care and assessments, ensuring proper management of superficial injuries or conditions like dermatitis in clinical practice.

Choice B reason: Adipose tissue is deep, within the subcutaneous layer, not superficial. The epidermis is the outermost layer. Misidentifying adipose risks misunderstanding skin anatomy, leading to errors in wound staging or treatment, potentially compromising care for superficial skin conditions requiring targeted interventions like topical therapies.

Choice C reason: The subcutaneous layer lies beneath the dermis, not superficially. The epidermis is the outermost layer. Assuming subcutaneous is superficial misguides skin assessments, risking incorrect wound care or misdiagnosis of skin conditions, critical for accurate treatment and prevention of complications in integumentary health.

Choice D reason: The dermis lies below the epidermis, containing blood vessels and nerves, not the most superficial layer. Misidentifying dermis risks errors in assessing skin injuries or conditions, potentially leading to inappropriate treatments. Recognizing the epidermis ensures proper care for superficial issues like burns or abrasions in clinical settings.

A. Stage 4. B. Stage 3. C. Stage 1. D. Stage 2.

Correct Answer is A

Explanation

Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.

Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.

Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.

Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.

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What is an unexpected finding for the integumentary system assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most superficial layer of skin called?

Correct Answer is A

Explanation

You are assessing a client and note a pressure injury on the client’s sacrum. The lesion is a deep depression below the level of skin and into the muscle and there appears to be a spot where the bone is visible. What stage of the pressure injury would you document for this wound?

Correct Answer is A

Explanation

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