The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

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Fundamentals of Nursing Skin Integrity Questions Questions

Question 1 of 5

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

Correct Answer: A

Rationale: Pressure points' are priority in skin integrity assessment. Bony prominences e.g., heels risk ulcers e.g., 60% of cases unlike 'breath sounds' , respiratory e.g., not skin. 'Bowel sounds' track digestion e.g., indirect. 'Pulse points' check flow e.g., secondary. A nurse inspects e.g., Sacrum red' per visual/tactile need, a physiological must. The text emphasizes pressure sites, making the correct, top focus.

Question 2 of 5

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Correct Answer: D

Rationale: A Braden score of '23' best shows risk removed. Perfect score e.g., 6-23 range means no risk e.g., all 4s unlike '12' or '13' , high risk e.g., <16. '20' is safe e.g., >18 but not max. A nurse reassesses e.g., 23, no risk' per 90% intervention success, a physiological goal. The text sets 18 as cutoff, 23 as ideal, making the correct, optimal sign.

Question 3 of 5

What happens when the arrector pili muscles contract?

Correct Answer: A

Rationale: Goose bumps' occur when arrector pili contract, per ProProfs. Tiny muscles e.g., 1 mm raise hairs e.g., cold response unlike 'sweat release' , gland-driven e.g., no link. 'Hair shed' is cycle-based e.g., not instant. 'Skin color change' is vascular e.g., unrelated. A biologist sees e.g., Bumpy chill' per heat/trap instinct, a physiological reaction. The quiz ties this to hair standing, making the correct, bumpy result.

Question 4 of 5

Which of the following best describes an unintentional wound?

Correct Answer: B

Rationale: Jagged wound edges, uncontrolled bleeding' describes an unintentional wound, . Accidents e.g., falls tear e.g., 2 cm, 50 mL unlike 'clean edges' or 'low infection risk' , surgical e.g., planned. 'Surgery, IV' is intentional e.g., not accidental. A nurse sees e.g., Rough, bloody' per trauma type, a physiological distinction. The text contrasts this with intentional, making the correct, unintentional descriptor.

Question 5 of 5

What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings?

Correct Answer: B

Rationale: Implement a turning schedule every 2 hours' prevents ulcers. Q2h e.g., 30° lateral cuts pressure e.g., <32 mmHg unlike 'once per shift' , too long e.g., 8 hr risk. 'Ring cushions' pinch e.g., contraindicated. 'No turn, support surface' lacks e.g., needs both. A nurse plans e.g., Turn q2h' per 80% prevention, a physiological must. The text mandates this, making the correct, key intervention.

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