1. The nurse is inspecting Josephine Morrow's skin. To which areas should the nurse pay close
attention while performing a physical assessment? (Select all that apply.): Under the breasts, Groin,
Arms and legs, Sacrum
Rationale:Because Josephine Morrow is obese, the nurse should pay particular attention to the
areas that are prone to skin breakdown and fungal skin infections: under the breasts as well as
folds of skin in the groin, arms, and legs. Patients who are obese frequently perspire, and the
skin in these areas is prone to friction. In addition, patients who are obese require assistance in
movement and repositioning, increasing the likelihood of skin breakdown, so the sacrum is
important to assess. The nurse can also assess the hair, scalp, eyes, ears, and surface of the
abdomen, but these areas are not ones likely to be of major concern
2. The nurse recognizes that Josephine Morrow's limited mobility can have adverse effects on the
skin. What other information would the nurse need to gather to establish priorities for the plan of
care? (Select all that apply.): Fall risk, Nutritional status, Smoking history, Hygiene
status/practices, Circulation status
Rationale:To establish priorities for the plan of care, the nurse would need to gather information
about fall risk, nutritional status, smoking history, hygiene practices, and circulation status. Risk
factors that can lead to skin breakdown and pressure injuries include poor circulation, poor
hygiene, infrequent position changes, dermatitis, infection, and traumatic wounds. The nurse
should use a skin assessment tool to assess the patient for risk for injury development, scoring
six factors in the matrix to assess the patient's risk for breakdown: sensory perception,
moisture, activity, mobility, nutrition, and friction and shear. A smoking history is needed
because smoking can contribute to decreased oxygen available to the wounds, and oxygen is
essential for healing. A patient's family history does not have a direct correlation to a patient's
limited mobility and subsequent risks for skin breakdown.
3. The nurse recognizes that Josephine Morrow is at a high risk for the
Development of Choose
Answer.. Due to
Choose Answer..: Correct Response:Blank-1. Deep vein thrombosis (DVT) Blank-2. Decreased
mobility
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