dry skin xerosis can lead to itching pruritis what statement by the client indicates need for further teaching about preventing dry skin
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

Correct answer: B

Rationale:

2. What is an example of a client's primary defense to infection?

Correct answer: A

Rationale:

3. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

4. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

Correct answer: B

Rationale:

5. What is a priority intervention when caring for a client in Buck’s traction?

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

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