The skin receives stimuli from the outside world, providing a ...

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The skin receives stimuli from the outside world, providing a dynamic interaction between external and internal environments.
 
  Based on this information, what is the best nursing action that a nurse can implement for a client who has a loss of sensation to the integumentary system? A) Be careful when handling the arms of clients.
  B) Inspect for skin tears.
  C) Inspect skin frequently, especially bony prominences.
  D) Discourage smoking and exposure to the sun.

Question 2

The steps in the nursing process lead to specific results. The characteristics of the nursing process are critical to its effectiveness. Based on this information, which description best demonstrates a systematic approach to nursing care?
 
  A) The nurse follows specific, orderly, and logical steps based on the client's most important and often most vital needs.
  B) The nurse focuses on meeting individualized client needs, rather than on performing specific skills.
  C) Goals, objectives, or expected outcomes are established as an early part of the nursing process.
  D) Existing nursing process must be redesigned spontaneously to fit the most current and highest priority needs.

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Answer to Question 1

C
Feedback:
When an individual has loss of sensation, it is important to inspect the skin frequently, especially bony prominences. When the capillary bed in the dermis becomes more friable, the nurse should be careful when handling the arms of clients. When the epidermal and dermal layers flatten, the nurse should inspect for skin tears. When there is a loss of elasticity in the dermis, loss of subcutaneous layer of fat, and loss of collagen fibers, the client should be discouraged from smoking and exposure to the sun.

Answer to Question 2

A
Feedback:
The nursing process is systematic. The nurse follows specific, orderly, and logical steps based on the client's most important and often most vital needs, also known as prioritization or prioritizing. The nursing process is client-oriented. The nurse focuses on meeting individualized client needs, rather than on performing specific skills. The nursing process is goal-oriented. Goals, objectives, or expected outcomes are established as an early part of the nursing process. The nursing process is continuous. Because the life and health of individuals change, reassessment of the client's needs is done frequently, sometimes hourly (or more frequently in critical care settings). Therefore, the existing nursing process must be redesigned spontaneously to fit the most current and highest priority needs.

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