Skin Integrity HESI Case StudySet EXAM GRADED A+ QUESTIONS AND CORRECT
ANSWERS 100% VERIFIED
Meet the Client
A client with paraplegia as the result of a spinal cord injury received in a motorcycle
accident lives at home with their parents who assist with care. The client is attending
college and has a strong social support system. The client visits the health clinic on
campus for a regularly scheduled skin assessment, where the nurse observes a
reddish area on their sacrum.
Section 1
Assessment
The nurse observes that the reddish area is round and is directly over the client's
sacrum. The skin is intact.
In addition to measuring the length of time the redness lasts, which
assessment measure(s) should the nurse perform? (Select all that apply. One,
some, or all options may be correct.)
O Apply light pressure to the area with the fingertips.
O Measure the diameter of the redness.
O Obtain a wound culture.
O Gently lift a fold of skin.
O Observe for wound approximation.
- Apply light pressure to the area with the fingertips.
- Measure the diameter of the redness.
The sacral area has remained red for 2 hours and does not blanch when
tested. Which is the best description for the nurse to document?
O Excessive pallor.
O Unusual skin mottling.
O Dependent sacral rubor.
O Reactive hyperemia.
Reactive hyperemia.
The nurse identifies that the client has developed a Stage 1 pressure injury and is
concerned that the client may have other pressure injuries.
Which areas are most important for the nurse to observe for additional
pressure injuries (PI)?
O Distal tips of the toes.
O Lower abdominal folds.
O Ischial tuberosities.
O Thighs and calves.
Ischial tuberosities.
During the assessment of these high-risk areas, the nurse finds no redness, but the
underlying tissue feels spongy.
, What action should the nurse implement?
O Apply heat to reduce the inflammation that has occurred at these sites.
O Notify the healthcare provider (HCP) that the client is retaining excess fluid.
O Reassure the client that no pressure damage is present at these sites.
O Identify these areas as sites where pressure damage has occurred.
Identify these areas as sites where pressure damage has occurred.
Section 2
Nursing Diagnosis
The PN and RN team leader identify a priority problem for the client's plan of care as
"impaired skin integrity."
Which etiology identified by the nurse is accurate?
O Noncompliance with turning schedule.
O Poor nutritional intake.
O Impaired physical mobility.
O Impaired adjustment.
Impaired physical mobility.
After establishing the priority diagnosis, the nurse identifies goals and expected
outcomes.
Which goal should the nurses include in the client's plan of care?
O The client's skin will remain intact without deterioration.
O The client's motor function will be restored.
O Client teaching will be provided.
O Impaired skin integrity will not occur.
The client's skin will remain intact without deterioration.
Section 3
Self-Care Measures
At the end of the appointment, the nurse provides client teaching about measures to
promote healing and to prevent further tissue destruction.
To provide pressure relief at night, the nurse teaches the client to sleep in
which position?
O Supine with the head of the bed elevated.
O Supine with a foam wedge between the knees.
O Thirty-degree lateral inclined position.
O Full side-lying position supported with pillows.
Thirty-degree lateral inclined position.
Upon learning that the client has a pressure-reducing gel chair cushion for
their wheelchair, which action should the nurse take?
O Encourage them to continue to use this device in their wheelchair at all
times.
O Recommend that they replace the gel pad with a donut-shaped foam
cushion.
O Advise them to avoid the use of any form of pressure cushion on their
wheelchair.
ANSWERS 100% VERIFIED
Meet the Client
A client with paraplegia as the result of a spinal cord injury received in a motorcycle
accident lives at home with their parents who assist with care. The client is attending
college and has a strong social support system. The client visits the health clinic on
campus for a regularly scheduled skin assessment, where the nurse observes a
reddish area on their sacrum.
Section 1
Assessment
The nurse observes that the reddish area is round and is directly over the client's
sacrum. The skin is intact.
In addition to measuring the length of time the redness lasts, which
assessment measure(s) should the nurse perform? (Select all that apply. One,
some, or all options may be correct.)
O Apply light pressure to the area with the fingertips.
O Measure the diameter of the redness.
O Obtain a wound culture.
O Gently lift a fold of skin.
O Observe for wound approximation.
- Apply light pressure to the area with the fingertips.
- Measure the diameter of the redness.
The sacral area has remained red for 2 hours and does not blanch when
tested. Which is the best description for the nurse to document?
O Excessive pallor.
O Unusual skin mottling.
O Dependent sacral rubor.
O Reactive hyperemia.
Reactive hyperemia.
The nurse identifies that the client has developed a Stage 1 pressure injury and is
concerned that the client may have other pressure injuries.
Which areas are most important for the nurse to observe for additional
pressure injuries (PI)?
O Distal tips of the toes.
O Lower abdominal folds.
O Ischial tuberosities.
O Thighs and calves.
Ischial tuberosities.
During the assessment of these high-risk areas, the nurse finds no redness, but the
underlying tissue feels spongy.
, What action should the nurse implement?
O Apply heat to reduce the inflammation that has occurred at these sites.
O Notify the healthcare provider (HCP) that the client is retaining excess fluid.
O Reassure the client that no pressure damage is present at these sites.
O Identify these areas as sites where pressure damage has occurred.
Identify these areas as sites where pressure damage has occurred.
Section 2
Nursing Diagnosis
The PN and RN team leader identify a priority problem for the client's plan of care as
"impaired skin integrity."
Which etiology identified by the nurse is accurate?
O Noncompliance with turning schedule.
O Poor nutritional intake.
O Impaired physical mobility.
O Impaired adjustment.
Impaired physical mobility.
After establishing the priority diagnosis, the nurse identifies goals and expected
outcomes.
Which goal should the nurses include in the client's plan of care?
O The client's skin will remain intact without deterioration.
O The client's motor function will be restored.
O Client teaching will be provided.
O Impaired skin integrity will not occur.
The client's skin will remain intact without deterioration.
Section 3
Self-Care Measures
At the end of the appointment, the nurse provides client teaching about measures to
promote healing and to prevent further tissue destruction.
To provide pressure relief at night, the nurse teaches the client to sleep in
which position?
O Supine with the head of the bed elevated.
O Supine with a foam wedge between the knees.
O Thirty-degree lateral inclined position.
O Full side-lying position supported with pillows.
Thirty-degree lateral inclined position.
Upon learning that the client has a pressure-reducing gel chair cushion for
their wheelchair, which action should the nurse take?
O Encourage them to continue to use this device in their wheelchair at all
times.
O Recommend that they replace the gel pad with a donut-shaped foam
cushion.
O Advise them to avoid the use of any form of pressure cushion on their
wheelchair.
