HESI SKIN INTEGRITY LATEST FINAL EXAM UPDATED FOR 2026-2026 TOP SCORE COMPREHENSIVE QUESTIONS WITH 100% CERTIFIED, DETAILED & VERIFIED SOLUTIONS, ACE YOUR EXAMS- DEFINITE SUCCESS!!!

HESI SKIN INTEGRITY LATEST FINAL EXAM UPDATED FOR 2025-2026 TOP SCORE COMPREHENSIVE QUESTIONS WITH 100% CERTIFIED, DETAILED & VERIFIED SOLUTIONS, ACE YOUR EXAMS- DEFINITE SUCCESS!!! The nurse observes that the reddish area round, 3 cm diameter, and is directly over the client's sacrum. The skin is intact. In addition to measuring the length of the time the redness lasts, which assessment measure should the nurse perform? (select all that apply). A) Apply light pressure to the area with the fingertips. B) Measure the diameter of the redness. B) Observe for wound approximation. C) Obtain a wound culture D) Gently lift a fold of skin. A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching. This is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment. B)Measure the diameter of the redness. Rationale: the area of redness should be measured to evaluate progression or healing. The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding? A) Excessive pallor B) Unusual skin mottling C) Dependent sacral rubor D) Reactive hyperemia D) Reactive hyperemia Rationale: reactive hyperemia occurs when tissue is relieved of pressure. Is is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch. The nurse identifies that Aaron has developed a Stage I pressure ulcer. The nurse is concerned that Aaron may have other pressure ulcers. Which areas are most important for the nurse to observe for additional pressure ulcers? A) Distal tips of the toes. B) Lower abdominal folds C) Heels and ankles D) Thighs and calves C) Heels and ankles Rationale: pressure ulcers typically occur over bony prominences, such as the heels, and sacral area. While bony prominences are the most common sites for pressure ulcer development. the RN should perfom a complete skin assessment. 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? A) Apply heat to reduce the inflammation that has occurred at these sites? B) Notify the healthcare provider that the client is retaining excessive fluid C) Reassure the client that no pressure damage is present at these sites. D) Identify these areas as sites where pressure damage has occurred. D) Identify these areas as sites where pressure damage has occurred. Rationale: Palpable changes in the consistency of the tissue underlying a bony prominence, often described as :spongy" or "beefy," are an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration. The nurse identifies a priority problem for Aaron's plan of care as "Impaired skin integrity". What etiology should the nurse identify? A) Noncompliance with turning schedule B) Poor nutritional intake C) Impaired physical mobility D) Impaired adjustment C) Impaired physical mobility