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 C

Explanation

A. Only at the beginning of the hospital stay to establish a baseline. This is incorrect because while an initial assessment establishes a baseline, ongoing assessments are necessary to monitor changes in the patient’s condition.

B. Once a week during routine rounds. This is incorrect because patient conditions can change rapidly, and weekly assessments are insufficient for monitoring acute care patients.

C. At each shift change to identify any changes in the patient's condition. This is correct because ongoing assessments should be performed regularly, especially at the beginning of each shift. This allows the nurse to detect changes early, adjust care plans, and intervene as needed.

D. Only when the patient reports new symptoms. This is incorrect because waiting for a patient to report symptoms may delay critical interventions. Many conditions, such as sepsis or respiratory distress, can progress without the patient immediately recognizing symptoms. Routine monitoring helps identify early signs of deterioration.

A. Review the patient's medication history for any potential drug interactions. B. Educate the patient about the potential side effects of the new medication. C. Document the patient's baseline blood pressure before starting the medication. D. Assess the patient's blood pressure to determine if the medication is effective.

Correct Answer is D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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