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 B

Explanation

A. Pinpoint pupils: Pinpoint pupils may indicate opioid use or a brainstem injury but are not related to Babinski's sign.
B. Dorsiflexion of the great toe: This is the characteristic response for a positive Babinski sign, which occurs when the toes fan out and the big toe dorsiflexes (moves upward) when the sole of the foot is stroked. It indicates an abnormal response and potential upper motor neuron damage.
C. Jerking contractions of the head and neck: This is indicative of a seizure activity, not Babinski's sign.
D. Pronation of the arms: This could be indicative of decerebrate posturing, not Babinski's sign.

A. “As a nurse, I am required by law to report suspected child abuse.” B. "I reported the incident to my supervisor who decided to contact the authorities." C. "The provider will be coming to explain the situation." D. ”I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is A

Explanation

A. The nurse is legally obligated to report suspected child abuse according to mandatory reporting laws. This response directly addresses the nurse’s legal responsibility without providing unnecessary details to the parents.
B. Reporting the incident to a supervisor does not fully address the nurse's legal obligation, which is to report the abuse to the authorities.
C. It is inappropriate to defer to the provider in this case, as the nurse holds the legal responsibility to report the suspicion.
D. The nurse should not avoid the discussion but instead provide a clear, legal explanation for their actions.

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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 assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Correct Answer is B

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

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