A client has been admitted to the intensive care unit of the hospital after developing toxic epidermal necrolysis (TEN) consequent to the administration of a sulfonamide antibiotic. What pathophysiologic phenomenon is likely the greatest immediate threat to this client's health?

Correct Answer: D

Rationale: The correct answer is D. The presence of diffuse lesions and skin sloughing on the client's mucous membranes is the greatest immediate threat in toxic epidermal necrolysis (TEN). This condition results in severe skin detachment, leading to increased risk of infection, fluid loss, and electrolyte imbalances. Skin sloughing can also affect mucous membranes, increasing the risk of respiratory compromise, sepsis, and systemic infection. The other choices are not the greatest immediate threat in TEN. Bacterial cellulitis (choice A) is a potential complication but not the most immediate threat. Fluid and electrolyte imbalances (choice B) are significant but secondary to the skin sloughing. A cascading autoimmune response (choice C) can occur in TEN but is not the immediate threat compared to the risk of mucous membrane involvement and skin sloughing.

Correct Answer: D

Rationale: The skin's role in homeostasis includes temperature control, making 'thermal regulation by skin blood flow dilation or constriction'. The hypothalamus signals skin vessels to vasoconstrict e.g., conserving heat in cold (temp up 1°C) or vasodilate e.g., shedding heat in warmth (temp down 2°C) per Baranoski and Ayello (2004). , 'synthesis of vitamin K,' is false; skin makes vitamin D via UV e.g., 10 minutes sun yields 1000 IU not K, which liver produces. , 'elimination of carbon dioxide,' is lungs' job e.g., 35-45 mmHg CO2 exhaled, not skin. , 'glucose regulation by Langerhans cells,' misattributes; pancreatic islets, not skin's Langerhans (immune cells), manage glucose e.g., insulin drops 100 mg/dL. Skin's sweat and blood flow e.g., dilating vessels in 90°F heat regulate temp, a nurse's focus in fever or hypothermia. Unlike lungs or pancreas, skin's thermal role is dynamic, immediate, and measurable, aligning with essentials in *Wound Care Essentials*, making the accurate function.

Correct Answer: A

Rationale: A nonblanchable red area on the malleolus is 'Stage 1' , per Potter's *Essentials*. Intact skin with persistent erythema e.g., no lightening after 10 seconds marks early injury, unlike 'Stage 2' , partial-thickness e.g., open blister. 'Stage 3' is full-thickness e.g., fat exposed, not here. 'Stage 4' shows bone e.g., deep loss, not redness. A nurse records e.g., Malleolus red, intact' Stage 1's 60% progression risk, per NPUAP, needing padding. Potter notes Stage 1 as first warning, distinct from Stage 2's dermal breach, a physiological assessment staple. is the correct, initial stage.

Correct Answer: A

Rationale: The primary advantage of a 'hydrogel dressing' is to 'provide moisture needed for wound healing,' per Potter's *Essentials*. Moisture e.g., 90% water keeps granulation alive e.g., heals 50% faster unlike 'absorbent' , gauze's role e.g., drainage, not moisture. 'Negative pressure' is NPWT e.g., vacuums fluid, not hydrogel. 'Protection' fits hydrocolloids e.g., seals, not moistens. A nurse uses e.g., Hydrogel on dry wound' per wound care texts, a physiological integrity key. Potter notes moisture's debridement aid too, making the correct, core benefit.

Correct Answer: A

Rationale: The nurse assesses 'decreased level of consciousness' as a key pressure ulcer risk. Confused or unconscious patients e.g., post-stroke can't shift to relieve pressure e.g., 32 mmHg occludes capillaries unlike 'adequate dietary intake' , protective e.g., protein aids tissue. 'Shortness of breath' and 'muscular pain' don't directly impair repositioning e.g., not Braden factors. A nurse checks e.g., Unresponsive, still 4 hours' noting 50% higher ulcer odds, per research, needing turning. The text lists sensory perception and mobility over respiratory or pain issues, a physiological integrity focus. is the correct, predisposing factor.