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. Check the client's visual acuity using a Snellen chart: This assesses cranial nerve II (optic), not cranial nerve VII.
B. Observe for facial symmetry while the client smiles: This is the correct method to assess cranial nerve VII (facial nerve), which controls facial muscles, including those responsible for smiling.
C. Have the client identify specific smells: This tests cranial nerve I (olfactory), not cranial nerve VII.

D. Whisper in one of the client's ears while occluding the other: This assesses cranial nerve VIII (vestibulocochlear), not cranial nerve VII.

A. Have the client identify specific smells. B. Check the client's visual acuity using a Snellen chart. C. Observe for the ability of the client to turn their head side to sidê. D. Whisper in one of the client's ears while occluding the other.

Correct Answer is C

Explanation

A. Identifying specific smells checks cranial nerve I (olfactory).
B. Checking visual acuity with a Snellen chart assesses cranial nerve II (optic).
C. Observing for the ability to turn the head side to side tests cranial nerve XI (accessory), which controls the sternocleidomastoid and trapezius muscles responsible for head movement.
D. Whispering in one ear while occluding the other tests cranial nerve VIII (vestibulocochlear).

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Correct Answer is B

Explanation

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Correct Answer is C

Explanation

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