Skin assessment

  • NCLEX-PN
  • Reduction of Risk Potential
  • Drag and drop
  • Difficulty 3 of 5

Question

During a routine skin check of an adult client, sort each observation into the appropriate category. Treat each observation independently.

Expected

  • Warm, dry skin without swelling
  • Skin returns promptly after a gentle pinch

Unexpected

  • New yellow discoloration of skin
  • A newly cool extremity

Answer

Expected: Warm, dry skin without swelling; Skin returns promptly after a gentle pinch · Unexpected: New yellow discoloration of skin; A newly cool extremity

Rationale

A comfortable skin temperature and normal turgor fit an expected assessment. New color or temperature changes warrant follow-up.

RememberCompare new skin changes with expected temperature, color and turgor.

Sources

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