When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

Groin

Соссух

Heels

Scapula

Under the breasts

Answer and Explanation

Correct Answer : A,B,C,E

A.   The groin area is prone to skin breakdown due to friction, moisture, and pressure, especially in immobile patients.
B.   The coccyx (tailbone) is a high-risk area for pressure ulcers due to constant pressure when sitting, particularly in bedridden patients.
C.   The heels are vulnerable to pressure ulcers because they are under constant pressure when lying down or when standing for prolonged periods.
D.   While the scapula may be at risk in certain conditions (e.g., if the patient is immobile and lying on their back), it is generally not as high-risk as other areas like the coccyx or heels.
E.   This area is at risk due to moisture, friction, and pressure from the breast tissue, especially in obese or immobile patients.

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Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (optic), not cranial nerve III.
B. Eliciting the gag reflex: This assesses cranial nerve IX and X (glossopharyngeal and vagus), not cranial nerve III.
C. Observing for facial symmetry: This assesses cranial nerve VII (facial nerve), not cranial nerve III.
D. Checking the pupillary response to light: Cranial nerve III (oculomotor) is responsible for controlling pupil constriction in response to light, making this the correct method to assess cranial nerve III.

A. Pinnae of the ears B. Dorsal surface of the hand C. Dorsal surface of the foot D. Conjunctivae

Correct Answer is A

Explanation

A. Pinnae of the ears are one of the most reliable sites for detecting cyanosis in individuals with dark skin, as the color changes are more apparent in the mucous membranes and earlobes.
B. Dorsal surface of the hand may not reliably show cyanosis in darker skin tones, and it’s often less
visible.
C. Dorsal surface of the foot is not typically where cyanosis would be identified.
D. Conjunctivae can be used for detection in individuals with darker skin, but it is typically harder to visualize than the pinna.

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When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve IlI?

Correct Answer is D

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is A

Explanation

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

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