When assessing a patient with dark skin tones for suspected deep tissue injury, what should the nurse prioritize?
Checking for intact skin with a reddish-pink wound bed
Palpating for changes in skin temperature and moisture.
Noting slough or eschar over the wound bed.
Inspecting for erythema around bony prominences
The Correct Answer is B
A. Checking for intact skin with a reddish-pink wound bed: In patients with dark skin tones, color changes such as redness or pinkness may not be visible, making this an unreliable indicator of deep tissue injury.
B. Palpating for changes in skin temperature and moisture: For dark-skinned patients, tactile assessment—such as detecting warmth, coolness, induration, or bogginess—is more reliable for identifying underlying tissue damage. Palpation helps identify early deep tissue injury that may not be apparent visually.
C. Noting slough or eschar over the wound bed: Slough or eschar indicates more advanced pressure injury (Stage III or IV). It is not a primary method for detecting early deep tissue injury, which occurs beneath intact skin.
D. Inspecting for erythema around bony prominences: Erythema may be difficult to detect in darker skin tones, as the skin may appear darker, purple, or even as a different hue. Visual inspection alone is insufficient and should be supplemented with palpation and other assessment methods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide the spouse with educational materials about the client's condition: Offering information is helpful for understanding the client’s condition, but it does not directly address the spouse’s emotional state or demonstrate empathy. Emotional support requires acknowledgment of feelings.
B. Ask direct questions about their silence to get a response: Pressuring the spouse to speak may increase anxiety and inhibit communication. Empathy involves creating a safe, nonjudgmental space rather than forcing disclosure.
C. Focus on the client's needs and address the spouse's concerns later: Ignoring the spouse’s emotional cues can lead to feelings of isolation and distress. Providing support in the moment is essential for family-centered care.
D. Acknowledge the spouse's feelings by saying it seems like this situation might be overwhelming for you. What can I do to help?: This approach validates the spouse’s emotions and invites dialogue in a supportive way. It demonstrates empathy, encourages trust, and allows the nurse to respond to emotional needs while maintaining sensitivity to the family’s experience.
Correct Answer is D
Explanation
A. Activation of the parasympathetic nervous system: The parasympathetic system promotes “rest and digest” responses, including slowed heart rate and relaxation, which are opposite to the observed acute stress signs.
B. Decreased blood flow to muscles: During acute stress, blood flow to muscles actually increases to prepare for rapid physical response. Decreased perfusion would impair the body’s ability to respond to stress.
C. Release of insulin: Insulin primarily regulates blood glucose levels. During acute stress, insulin secretion is often suppressed to allow elevated glucose for energy, making this unrelated to the immediate stress response.
D. Activation of the sympathetic nervous system: The sympathetic nervous system triggers the “fight or flight” response, leading to tachycardia, rapid respirations, increased muscle tone, and mobilization of energy stores. These physiological changes align with the signs observed in acute stress reactions.
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