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. While an eye patch may be needed for other conditions (e.g., facial paralysis), it is not a primary concern in this case.
B. Range-of-motion exercises are not related to cranial nerve IX and X impairment.
C. Avoiding warm water to wash the face is not specifically relevant to cranial nerve impairment.
D. Suction equipment should be available for clients with cranial nerve impairment, especially if they have swallowing difficulties or potential for aspiration.

A. Testing visual acuity B. Eliciting the gag reflex C. Observing for facial symmetry D. Checking the pupillary response to light

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.

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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 caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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