Author Question: A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? ... (Read 95 times)

jerry coleman · **on:** Jul 22, 2018

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

a. A patient who is afebrile
b. A patient who is diaphoretic
c. A patient with strong pedal pulses
d. A patient with adequate skin turgor

Question 2

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says I always bathe in the evening. Which action by the nurse is best?

a. Defer the bath until evening and pass on the information to the next shift.
b. Tell the patient that daily morning baths are the normal routine.
c. Explain the importance of maintaining morning hygiene practices.
d. Cancel hygiene for the day and attempt again in the morning.

Jordin Calloway · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is.

Answer to Question 2

ANS: A
Allow the patient to follow normal hygiene practices; change the bath to evening. Patients have individual preferences about when to perform hygiene and grooming care. Knowing the patient's personal preferences promotes individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene and trying again is not an option since the nurse already knows the reason for refusal. Adapting practices to meet individual needs is required.