A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?
a. A patient who is afebrile
b. A patient who is diaphoretic
c. A patient with strong pedal pulses
d. A patient with adequate skin turgor
ANS: B
Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is.
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