The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
Pressure points
Breath sounds
Pulse points
Bowel sounds
The Correct Answer is A
A. Pressure points are critical to assess when evaluating skin integrity, particularly in patients who are immobile or bedridden, as these areas are at high risk for pressure ulcers.
B. Breath sounds are important but are not the priority in assessing skin integrity.
C. Pulse points assess circulation, but they are not directly related to skin integrity.
D. Bowel sounds are relevant for digestive assessments, not for skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.
A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.
Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.
Correct Answer is A
Explanation
A. Docusate sodium is a stool softener, and it may take 1-3 days to produce a bowel movement, so this statement reflects proper understanding.
B. Docusate is used to prevent constipation, not treat diarrhea, so this statement is incorrect.
C. Taking docusate sodium with mineral oil can increase the risk of absorption of mineral oil into the system, which is harmful, so this combination should be avoided.
D. The client should drink plenty of fluids, around 8 ounces or more, to help soften the stool.
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