Skin Integrity HESI Case Study with Complete
Solutions Graded A+
A client with paraplegia as the result of a spinal document?
cord injury received in a motorcycle accident O Excessive pallor.
lives at home with their parents who assist with O Unusual skin mottling.
care. The client is attending college and has a O Dependent sacral rubor.
strong social support system. The client visits the O Reactive hyperemia.
health clinic on campus for a regularly scheduled
skin assessment, where the nurse observes a
reddish area on their sacrum. - ANSWER -
Meet the Client Ischial tuberosities.
During the assessment of these high-risk areas,
the nurse finds no redness, but the underlying
The nurse observes that the reddish area is tissue feels spongy. - ANSWER -Which
round and is directly over the client's sacrum. areas are most important for the nurse to observe
The skin is intact. - ANSWER -Section 1 for additional pressure injuries (PI)?
Assessment O Distal tips of the toes.
O Lower abdominal folds.
O Ischial tuberosities.
O Thighs and calves.
- Apply light pressure to the area with the
fingertips.
- Measure the diameter of the redness. -
ANSWER -In addition to measuring the Identify these areas as sites where pressure
length of time the redness lasts, which damage has occurred. - ANSWER -What
assessment measure(s) should the nurse action should the nurse implement?
perform? (Select all that apply. One, some, or all O Apply heat to reduce the inflammation that has
options may be correct.) occurred at these sites.
O Apply light pressure to the area with the O Notify the healthcare provider (HCP) that the
fingertips. client is retaining excess fluid.
O Measure the diameter of the redness. O Reassure the client that no pressure damage
O Obtain a wound culture. is present at these sites.
O Gently lift a fold of skin. O Identify these areas as sites where pressure
O Observe for wound approximation. damage has occurred.
Reactive hyperemia. The PN and RN team leader identify a priority
problem for the client's plan of care as "impaired
The nurse identifies that the client has developed skin integrity." - ANSWER -Section 2
a Stage 1 pressure injury and is concerned that Nursing Diagnosis
the client may have other pressure injuries. -
ANSWER -The sacral area has remained
red for 2 hours and does not blanch when tested.
Which is the best description for the nurse to Impaired physical mobility.
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, Skin Integrity HESI Case Study with Complete
Solutions Graded A+
their wheelchair at all times. - ANSWER -
After establishing the priority diagnosis, the nurse Upon learning that the client has a pressure-
identifies goals and expected outcomes. - reducing gel chair cushion for their wheelchair,
ANSWER -Which etiology identified by the which action should the nurse take?
nurse is accurate? O Encourage them to continue to use this device
O Noncompliance with turning schedule. in their wheelchair at all times.
O Poor nutritional intake. O Recommend that they replace the gel pad with
O Impaired physical mobility. a donut-shaped foam cushion.
O Impaired adjustment. O Advise them to avoid the use of any form of
pressure cushion on their wheelchair.
O Teach them that regular use of skin moisturizer
is more important than cushion use.
The client's skin will remain intact without
deterioration. - ANSWER -Which goal
should the nurses include in the client's plan of
care? Transparent film dressing
O The client's skin will remain intact without
deterioration. The nurse also reminds the client to assess
O The client's motor function will be restored. pressure points using a long-handled mirror twice
O Client teaching will be provided. a day. - ANSWER -The nurse teaches the
O Impaired skin integrity will not occur. client to apply a dressing over the sacral area.
Which type of dressing is most likely to be used
over the stage 1 PI?
O Transparent film dressing.
At the end of the appointment, the nurse O Adherent film dressing.
provides client teaching about measures to O Gauze dressing.
promote healing and to prevent further tissue O Hydrogel covered with a foam dressing.
destruction. - ANSWER -Section 3
Self-Care Measures
A month later, the client arrives in the emergency
department at the local hospital and reports
Thirty-degree lateral inclined position. - having had the flu and has spent most of their
ANSWER -To provide pressure relief at time in bed for the last several days. The client
night, the nurse teaches the client to sleep in has been experiencing vomiting and diarrhea.
which position? The nurse observes that the sacral PI is open,
O Supine with the head of the bed elevated. has a crater-like appearance, and is draining a
O Supine with a foam wedge between the knees. large amount of thick yellow-tan fluid with an
O Thirty-degree lateral inclined position. unpleasant odor. A small amount of eschar is
O Full side-lying position supported with pillows. present. The client is admitted to the hospital with
a fever, fluid volume deficit, and possible sepsis.
- ANSWER -Section 4
A Complication Occurs
Encourage them to continue to use this device in
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Solutions Graded A+
A client with paraplegia as the result of a spinal document?
cord injury received in a motorcycle accident O Excessive pallor.
lives at home with their parents who assist with O Unusual skin mottling.
care. The client is attending college and has a O Dependent sacral rubor.
strong social support system. The client visits the O Reactive hyperemia.
health clinic on campus for a regularly scheduled
skin assessment, where the nurse observes a
reddish area on their sacrum. - ANSWER -
Meet the Client Ischial tuberosities.
During the assessment of these high-risk areas,
the nurse finds no redness, but the underlying
The nurse observes that the reddish area is tissue feels spongy. - ANSWER -Which
round and is directly over the client's sacrum. areas are most important for the nurse to observe
The skin is intact. - ANSWER -Section 1 for additional pressure injuries (PI)?
Assessment O Distal tips of the toes.
O Lower abdominal folds.
O Ischial tuberosities.
O Thighs and calves.
- Apply light pressure to the area with the
fingertips.
- Measure the diameter of the redness. -
ANSWER -In addition to measuring the Identify these areas as sites where pressure
length of time the redness lasts, which damage has occurred. - ANSWER -What
assessment measure(s) should the nurse action should the nurse implement?
perform? (Select all that apply. One, some, or all O Apply heat to reduce the inflammation that has
options may be correct.) occurred at these sites.
O Apply light pressure to the area with the O Notify the healthcare provider (HCP) that the
fingertips. client is retaining excess fluid.
O Measure the diameter of the redness. O Reassure the client that no pressure damage
O Obtain a wound culture. is present at these sites.
O Gently lift a fold of skin. O Identify these areas as sites where pressure
O Observe for wound approximation. damage has occurred.
Reactive hyperemia. The PN and RN team leader identify a priority
problem for the client's plan of care as "impaired
The nurse identifies that the client has developed skin integrity." - ANSWER -Section 2
a Stage 1 pressure injury and is concerned that Nursing Diagnosis
the client may have other pressure injuries. -
ANSWER -The sacral area has remained
red for 2 hours and does not blanch when tested.
Which is the best description for the nurse to Impaired physical mobility.
1/7
, Skin Integrity HESI Case Study with Complete
Solutions Graded A+
their wheelchair at all times. - ANSWER -
After establishing the priority diagnosis, the nurse Upon learning that the client has a pressure-
identifies goals and expected outcomes. - reducing gel chair cushion for their wheelchair,
ANSWER -Which etiology identified by the which action should the nurse take?
nurse is accurate? O Encourage them to continue to use this device
O Noncompliance with turning schedule. in their wheelchair at all times.
O Poor nutritional intake. O Recommend that they replace the gel pad with
O Impaired physical mobility. a donut-shaped foam cushion.
O Impaired adjustment. O Advise them to avoid the use of any form of
pressure cushion on their wheelchair.
O Teach them that regular use of skin moisturizer
is more important than cushion use.
The client's skin will remain intact without
deterioration. - ANSWER -Which goal
should the nurses include in the client's plan of
care? Transparent film dressing
O The client's skin will remain intact without
deterioration. The nurse also reminds the client to assess
O The client's motor function will be restored. pressure points using a long-handled mirror twice
O Client teaching will be provided. a day. - ANSWER -The nurse teaches the
O Impaired skin integrity will not occur. client to apply a dressing over the sacral area.
Which type of dressing is most likely to be used
over the stage 1 PI?
O Transparent film dressing.
At the end of the appointment, the nurse O Adherent film dressing.
provides client teaching about measures to O Gauze dressing.
promote healing and to prevent further tissue O Hydrogel covered with a foam dressing.
destruction. - ANSWER -Section 3
Self-Care Measures
A month later, the client arrives in the emergency
department at the local hospital and reports
Thirty-degree lateral inclined position. - having had the flu and has spent most of their
ANSWER -To provide pressure relief at time in bed for the last several days. The client
night, the nurse teaches the client to sleep in has been experiencing vomiting and diarrhea.
which position? The nurse observes that the sacral PI is open,
O Supine with the head of the bed elevated. has a crater-like appearance, and is draining a
O Supine with a foam wedge between the knees. large amount of thick yellow-tan fluid with an
O Thirty-degree lateral inclined position. unpleasant odor. A small amount of eschar is
O Full side-lying position supported with pillows. present. The client is admitted to the hospital with
a fever, fluid volume deficit, and possible sepsis.
- ANSWER -Section 4
A Complication Occurs
Encourage them to continue to use this device in
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