- Study guides, Class notes & Summaries

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - ANSWER - Apply light pressure to the area with the fingertips. Measure the diameter of the redness. The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? - ANSWER -

Skin integrity HESI Questions and Answers

A client with paraplegia as the result of a spinal cord injury received in a motorcycle accident lives at home with their parents who assist with care. The client is attending college and has a strong social support system. The client visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on their sacrum. - ANSWER - Meet the Client The nurse observes that the reddish area is round and is dir

Skin integrity HESI In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - ANSWER-Apply light pressure to the area with the fingertips. Measure the diameter of the redness. The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? - ANSWER-Reactive hyperemia. Which areas are most important for the nurse to observe for additional pressure ulcers? - ANSWER-H...