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 D
Explanation
Choice A reason: Urinary retention involves inability to empty the bladder, causing overflow, not involuntary leakage during laughing or sneezing, which indicates stress incontinence. Misdiagnosing retention risks inappropriate treatments like catheterization, delaying pelvic exercises or medications, critical for managing stress incontinence and improving quality of life in affected patients.
Choice B reason: Constipation affects bowel function, not urinary control, unlike stress incontinence, where leakage occurs during physical stress like sneezing. Assuming constipation misguides diagnosis, risking neglect of urinary interventions like Kegel exercises, essential for strengthening pelvic muscles and preventing incontinence-related limitations in daily activities.
Choice C reason: Hiatal hernia causes gastrointestinal symptoms like reflux, not urinary leakage during activities, which defines stress incontinence. Misdiagnosing hernia risks overlooking pelvic floor issues, delaying treatments like biofeedback, critical for managing incontinence, reducing activity limitations, and improving comfort in patients with stress-related urine loss.
Choice D reason: Stress incontinence involves involuntary urine leakage during activities like laughing or sneezing due to weakened pelvic floor muscles, common in women. Recognizing this guides interventions like pelvic exercises or surgery, critical for reducing activity limitations, improving quality of life, and addressing physical and emotional impacts in affected patients.
Correct Answer is C
Explanation
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
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