Which of the following assessments should be performed to monitor for impaired tissue integrity?

Pupil size and reaction

Heart rate and blood pressure

Respiratory rate and oxygen saturation

Skin turgor and moisture

Answer and Explanation

The Correct Answer is D

A.   Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B.   Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C.   Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D.   Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

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Correct Answer is B

Explanation

A. A person with diabetes who requires hospitalization for cellulitis: Cellulitis may not necessarily be a healthcare-associated infection unless it developed as a complication during the hospitalization.
B. Pneumonia in a hospitalized patient: Pneumonia acquired during a hospital stay is considered a healthcare-associated infection (HAI) because it develops after 48 hours of hospital admission.
C. Chronic urinary tract infection for a homebound patient: A chronic urinary tract infection in a homebound patient is not automatically considered a healthcare-associated infection unless it can be directly linked to healthcare interventions or devices.
D. A sexually transmitted infection in a healthy young adult: Sexually transmitted infections are not healthcare-associated infections as they are typically acquired through sexual contact rather than healthcare settings.

A. Skin lesions are seen as solid predictors of the general health state. B. The patient's psychological health is best predicted by the skin. C. Detection of skin cancer is the only reason to assess the client's skin. D. The skin is a good communicator regarding the client's overall health.

Correct Answer is D

Explanation

A. Skin lesions are seen as solid predictors of the general health state: While skin lesions can provide valuable information about a patient's health, they are not the only indicator. Changes in the skin can indicate various health conditions, not just lesions.
B. The patient's psychological health is best predicted by the skin: While changes in the skin can sometimes be associated with psychological health conditions, they are not the sole predictors. Psychological health is assessed through a comprehensive evaluation, including observation, interview, and assessment tools.
C. Detection of skin cancer is the only reason to assess the client's skin: While skin cancer detection is an important aspect of skin assessment, it is not the only reason. Skin assessment provides valuable information about overall health, hydration status, circulation, and potential systemic conditions.
D. The skin is a good communicator regarding the client's overall health: The skin can provide valuable clues about a patient's overall health status. Changes in skin color, texture, moisture, and integrity can indicate underlying health conditions, nutritional deficiencies, circulation problems, or systemic diseases. Therefore, focusing on any changes noted in the patient's skin is essential for comprehensive assessment and early detection of potential health issues.

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Which of the following assessments should be performed to monitor for impaired tissue integrity?

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Naxlex Comprehensive Predictor Exams

Which of the following infections would the nurse recognize as being a health care-associated infection?

Correct Answer is B

Explanation

The nurse in a healthcare provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

Correct Answer is D

Explanation

The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Which of the following assessments should be performed to monitor for impaired tissue integrity?

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A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

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