Which of the following goals is most appropriate when caring for a client at risk for skin breakdown?
The nurse will apply barrier cream to pressure areas.
The nurse will assess the client's skin daily.
The client will maintain intact skin.
The client will be pain free.
The Correct Answer is C
A. This is an intervention, not a goal. Applying barrier cream is a specific nursing action used to prevent skin breakdown, but goals should focus on desired client outcomes rather than tasks performed by the nurse.
B. Assessing the skin is an important part of care and a nursing intervention, but it does not describe the expected end result or outcome for the client. Goals should reflect what the client is expected to achieve or maintain.
C. This is the most appropriate goal for a client at risk for skin breakdown. It is client-centered, measurable, and outcome-oriented, indicating the desired result of nursing interventions. Maintaining intact skin directly reflects prevention of pressure injuries, abrasions, or other skin compromise.
D. While minimizing pain is important, it is not the primary goal related to the risk of skin breakdown unless the client is already experiencing painful lesions. The priority for a client at risk is preventing skin compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An older adult with fragile skin and a new dark red bruise is of greatest concern. Older adults often have thinner, more fragile skin due to aging, making them more susceptible to skin tears, bruising, and pressure injuries. A new dark red bruise may indicate trauma, potential falls, or even elder abuse, which requires immediate assessment and follow-up. Monitoring for hematomas, skin integrity, and underlying causes is critical.
B. A child with fine vellus hair and no signs of rash represents a normal skin finding in children. Fine, soft vellus hair is expected, and without any rashes, lesions, or other abnormalities, there is no immediate concern.
C. A pregnant client with increased sweating and mild skin darkening is experiencing normal physiological changes of pregnancy, such as hyperpigmentation (linea nigra, melasma) and increased diaphoresis. These are typically benign and do not indicate urgent pathology.
D. An adolescent with mild acne and oily skin is experiencing common hormonal skin changes of puberty. While acne management may be appropriate, it is not an immediate concern for acute skin compromise or systemic issues.
Correct Answer is D
Explanation
A. Bounding peripheral pulses and elevated blood pressure are more characteristic of fluid overload or hypertension, not dehydration. In dehydration, pulses are typically weak or thready, and blood pressure may be low due to reduced circulating volume. Therefore, this finding does not align with severe dehydration and is not the most urgent concern.
B. Erythema to the face and warm dry skin can occur with fever or mild dehydration but is not immediately life-threatening. While it warrants monitoring, it does not indicate severe hypovolemia requiring urgent intervention.
C. Pink nail beds and brisk capillary refill indicate adequate perfusion and oxygenation, which suggests the client’s cardiovascular status is relatively stable. This is reassuring and does not require immediate follow-up.
D. Tenting skin turgor and pale mucous membranes are classic signs of severe dehydration and indicate significant fluid loss and hypovolemia. Tenting shows reduced skin elasticity, while pale mucous membranes reflect poor perfusion and decreased circulating volume. These findings require immediate follow-up because the client is at risk for hypovolemic shock, organ hypoperfusion, and electrolyte imbalances, all of which can be life-threatening.
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