Which of the following signs is most indicative of impaired skin integrity?

Skin feeling warm to the touch

Presence of a wound with partial thickness skin loss

Dry skin with no visible lesions

Slight redness of the skin after applying pressure

Answer and Explanation

The Correct Answer is B

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

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Correct Answer is B

Explanation

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

A. Involve the multidisciplinary team B. Involve the family members C. Get patient input when making the plan D. Start planning at admission

Correct Answer is C

Explanation

A. While teamwork is crucial, patient input should come first to ensure the plan aligns with their needs and capabilities.

B. Family involvement is beneficial, but the patient should have the primary role in decision-making.

C. Effective discharge planning is patient-centered, ensuring that goals align with their preferences, abilities, and resources.

D. Although discharge planning should begin at admission, the most important factor for success is patient involvement.

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Which of the following signs is most indicative of impaired skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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