Which of the following signs is most indicative of impaired skin integrity?

Skin feeling warm to the touch

Presence of a wound with partial thickness skin loss

Dry skin with no visible lesions

Slight redness of the skin after applying pressure

Answer and Explanation

The Correct Answer is B

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

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Correct Answer is C

Explanation

A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.

B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.

C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.

D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.

A. Risk B. Actual C. Syndrome D. Wellness

Correct Answer is B

Explanation

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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Which of the following signs is most indicative of impaired skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

Correct Answer is C

Explanation

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Correct Answer is B

Explanation

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