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 A

Explanation

A. "Silvery, white scales": This is the classic presentation of psoriasis, a chronic skin disorder that results in the rapid turnover of skin cells, leading to thick, scaly patches, usually on the scalp, elbows, and knees.
B. Serous drainage: This is more common in conditions like infected wounds or abscesses, not psoriasis.
C. Intense pain: Psoriasis can cause discomfort, but it is typically not painful unless there are complications such as cracks or secondary infections.
D. Unilateral lesions: Psoriasis typically affects both sides of the body symmetrically, not unilaterally.

A. Potassium level B. Prealbumin/ level C. History of diabetes mellitus D. History of hyperlipidemia E. wound infection F. Decreased pedal perfusion G. Fasting blood glucose

Correct Answer is ["B","C","F"]

Explanation

A. The potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L), so there is no immediate concern. There is no abnormality in this lab value that needs to be addressed in this context.
B. The client's prealbumin level is 10 mg/dL, which is below the normal range (15 to 36 mg/dL). This is concerning as it indicates poor nutritional status, which can affect wound healing. Prealbumin is a sensitive indicator of nutritional status and is important in assessing the client's ability to heal from a pressure injury.
C. The client's history of diabetes mellitus is significant in this case. Diabetes can affect circulation, impair wound healing, and increase the risk of infections. Poor blood sugar control can contribute to delayed wound healing, so this is an important factor to consider.
D. While hyperlipidemia can contribute to cardiovascular issues, it is less directly related to wound healing in this case compared to diabetes mellitus. Although important to manage, it is not the most pressing issue in this context.

E. At this time, the wound shows no signs of infection. The surrounding skin is inflamed and red, which could be a sign of irritation or early pressure injury development, but there is no indication of infection (such as purulent drainage, increased pain, or fever) noted in the nursing notes.
F. The client's pedal pulse in the left foot is weak (1+), which indicates decreased perfusion to that extremity. Impaired circulation is a concern, especially in a client with diabetes, as it can further complicate wound healing. This is a critical factor to monitor closely.
G. The client's fasting blood glucose is elevated at 186 mg/dL, above the normal range (74 to 106 mg/dL). Elevated blood glucose levels can impair wound healing and increase the risk of infection, particularly in a client with diabetes.

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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 in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

Correct Answer is A

Explanation

A nurse is caring for a client. Exhibits

Correct Answer is ["B","C","F"]

Explanation

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