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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. A family history of skin cancer can increase the risk of developing the condition.
B. While individuals with dark skin have a lower risk of developing skin cancer, they are not immune to it, and this option is not as strong a risk factor as others.
C. Prior skin injuries, such as burns or scars, can increase the likelihood of skin cancer developing in those areas.
D. Skin cancer risk generally increases with age, making this not a strong risk factor.
E. UV light is a major risk factor for developing skin cancer due to its damage to skin cells and DNA.
Correct Answer is A
Explanation
A. Assess risk for immediate harm should be the priority. The nurse needs to evaluate whether the client is in immediate danger and take the necessary steps to ensure their safety.
B. Instructing the client on how to leave the relationship is important, but the priority is to assess if the client is in immediate danger first.
C. Implementing a safety plan is essential, but first, the nurse must assess the immediate risks to the client's safety.
D. Referring the client to a community support group is a supportive action but should follow the priority steps of ensuring safety and assessing immediate harm.
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