NCLEX - W10 - Hygiene & Skin Integrity

Question 1

Question: A nurse is caring for a patient who is experiencing a decreased appetite secondary to mouth pain. What is the priority action for the nurse to take?
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A. Administer pain medication as ordered.
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B. Provide oral care before and after meals.
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C. Encourage family members to bring in the patient’s favorite foods.
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D. Consult a registered dietitian for nutritional recommendations.

Answer 1

Answer: B. Provide oral care before and after meals.

Rationale: Oral care can improve appetite, especially when pain is present. While other options may be appropriate, addressing oral hygiene is the priority. A clean mouth promotes a sense of well-being and can enhance the taste of food.

Question 2

Question: The nurse is assessing a patient’s skin and notices a non-blanchable red area over the sacrum. What should the nurse do next?
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A. Massage the area to improve blood flow.
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B. Apply a warm compress to the area.
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C. Document the finding and continue to monitor.
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D. Reposition the patient and reassess the area in one hour.

Answer 2

Answer: D. Reposition the patient and reassess the area in one hour.

Rationale: Non-blanchable redness is a sign of potential deep tissue damage and a stage 1 pressure injury. Repositioning is essential to relieve pressure.

Question 3

Question: Which patient is at the highest risk for developing a pressure injury?
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A. A 30-year-old patient with a fractured femur who is in traction.
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B. A 55-year-old patient who is post-operative following a laparoscopic cholecystectomy.
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C. A 70-year-old patient with dementia who is incontinent of urine and stool.
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D. A 45-year-old patient with pneumonia who is receiving oxygen therapy.

Answer 3

Answer: C. A 70-year-old patient with dementia who is incontinent of urine and stool.

Rationale: Several factors put this patient at high risk, including age, dementia (potentially leading to immobility), and incontinence (moisture exposure).

Question 4

Question: A nurse is providing hygiene care to a patient who is unconscious. What is the most important consideration?
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A. Use minimal water to avoid skin maceration.
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B. Speak to the patient as if they were awake.
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C. Avoid using any scented soaps or lotions.
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D. Perform the care quickly to minimize discomfort.

Answer 4

Answer: B. Speak to the patient as if they were awake.

Rationale: Always assume that an unconscious patient can hear you. Explain procedures and provide respectful care.

Question 5

Question: A nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
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A. Partial-thickness wound repair
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B. Full-thickness wound repair
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C. Primary intention
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D. Tertiary intention

Answer 5

Answer: B. Full-thickness wound repair

Rationale: A stage IV pressure ulcer involves extensive tissue loss, requiring full-thickness wound repair.

Question 6

Question: A nurse is preparing to irrigate a patient’s wound. What is the primary reason for performing this procedure?
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A. To apply a topical antibiotic to the wound bed.
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B. To remove debris and bacteria from the wound.
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C. To promote the formation of granulation tissue.
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D. To assess the depth and size of the wound.

Answer 6

Answer: B. To remove debris and bacteria from the wound.

Rationale: Wound irrigation is used to cleanse the wound, not specifically for antibiotic application, promoting granulation tissue, or assessing depth and size

Question 7

Question: A nurse is teaching a patient about foot care. What information should the nurse include for a patient with diabetes?
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A. Soak your feet in hot water daily.
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B. Apply lotion between your toes.
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C. Inspect your feet daily for cuts or sores.
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D. Trim your toenails into a curved shape.

Answer 7

Answer: C. Inspect your feet daily for cuts or sores.

Rationale: Patients with diabetes are at high risk for foot complications due to neuropathy and poor circulation. Daily inspection is crucial.

Question 8

Question: The nurse is caring for a patient who has a Braden Scale score of 12. What does this score indicate?
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A. Low risk for pressure injury
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B. Moderate risk for pressure injury
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C. High risk for pressure injury
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D. The patient has a pressure injury.

Answer 8

Answer: C. High risk for pressure injury.

Rationale: A Braden Scale score of 12 indicates a high risk for developing a pressure injury. Lower scores indicate higher risk.

Question 9

Question: A nurse observes serosanguineous drainage from a patient’s surgical wound. What does this type of drainage indicate?
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A. A normal part of the healing process.
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B. A possible wound infection.
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C. The patient is experiencing internal bleeding.
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D. The wound is healing by tertiary intention.

Answer 9

Answer: A. A normal part of the healing process.

Rationale: Serosanguineous drainage is a mix of blood and serum, common in healing surgical wounds

Question 10

Question: A nurse is caring for a patient who has a Hemovac drain in place. What is the primary purpose of this drain?
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A. To irrigate the wound with saline solution.
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B. To prevent the formation of a hematoma.
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C. To collect excess blood and fluid from the surgical site.
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D. To provide a pathway for the administration of antibiotics.

Answer 10

Answer: C. To collect excess blood and fluid from the surgical site.

Rationale: A Hemovac drain removes fluids that could accumulate in a closed wound and delay healing or cause infection.

Question 11

Question: A nurse is providing perineal care to a female patient. What direction should the nurse use when cleansing?
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A. From back to front.
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B. From front to back.
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C. In a circular motion.
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D. It doesn’t matter as long as soap and water are used.

Answer 11

Answer: B. From front to back.

Rationale: Cleansing from front to back prevents the spread of bacteria from the anal area to the urethra, reducing the risk of urinary tract infections.

Question 12

Question: A nurse is caring for a patient who is on bed rest. Which action is most effective in preventing foot drop?
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A. Apply lotion to the patient’s feet daily.
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B. Place a pillow under the patient’s knees.
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C. Encourage the patient to range their ankles.
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D. Use a footboard to keep the patient’s feet flexed.

Answer 12

Answer: D. Use a footboard to keep the patient’s feet flexed.

Rationale: A footboard helps maintain proper foot positioning and prevents shortening of the calf muscles, which can lead to foot drop.

Question 13

Question: A patient’s abdominal wound has eviscerated. What should be the nurse’s first action?
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A. Immediately notify the healthcare provider.
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B. Apply direct pressure to the wound.
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C. Cover the wound with sterile saline-soaked dressings.
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D. Place the patient in a supine position with knees bent.

Answer 13

Answer: C. Cover the wound with sterile saline-soaked dressings.

Rationale: Evisceration is a surgical emergency. Immediate action is to cover the exposed viscera with moist, sterile dressings. Then, notify the provider.

Question 14

Question: When assisting a patient with a bed bath, the nurse should:
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A. Use hot water for a more thorough cleaning.
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B. Wash the patient’s face first.
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C. Keep the patient completely covered throughout the bath.
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D. Change the water whenever it becomes soapy.

Answer 14

Answer: B. Wash the patient’s face first.

Rationale: Generally, washing from cleaner areas (face) to dirtier areas is recommended for bed baths. Water temperature should be comfortable for the patient, and privacy should be maintained.

Question 15

Question: A nurse is caring for a patient who is receiving enteral feedings. Which nursing action is most important in preventing aspiration?
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A. Elevate the head of the bed during and after feedings.
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B. Check for gastric residual volume every 4 hours.
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C. Flush the feeding tube with water before and after medication administration.
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D. Warm the formula to room temperature before administering.

Answer 15

Answer: A. Elevate the head of the bed during and after feedings.

Rationale: Keeping the head of the bed elevated reduces the risk of regurgitation and aspiration.

Question 16

Question: A nurse is assessing a patient’s wound and notes that it is covered in thick, yellow slough. What does this finding indicate?
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A. The wound is infected.
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B. The wound is healing properly.
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C. The wound requires debridement.
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D. The wound should be kept dry.

Answer 16

Answer: C. The wound requires debridement.

Rationale: Slough is dead tissue that must be removed for the wound to heal.

Question 17

Question: Which of the following is an example of a chronic wound?
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A. A surgical incision that is healing by primary intention.
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B. A burn wound that is in the proliferative phase of healing.
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C. A pressure ulcer that has been present for 3 months.
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D. An abrasion that is covered with a dry scab.

Answer 17

Answer: C. A pressure ulcer that has been present for 3 months.

Rationale: Chronic wounds fail to heal within a typical timeframe. Pressure ulcers often fall into this category.

Question 18

Question: A patient is admitted with a suspected deep tissue injury. What assessment finding would support this diagnosis?
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A. A wound with exposed bone and tendon.
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B. A purple or maroon localized area of discolored, intact skin.
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C. An area of full-thickness skin loss with visible subcutaneous fat.
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D. A wound covered with eschar that cannot be staged.

Answer 18

Answer: B. A purple or maroon localized area of discolored, intact skin.

Rationale: This describes the appearance of a deep tissue injury, signaling potential extensive underlying damage.

Question 19

Question: A nurse is applying a hydrocolloid dressing to a patient’s stage 2 pressure injury. What is the rationale for using this type of dressing?
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A. It absorbs heavy drainage and prevents maceration.
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B. It provides a moist environment that promotes healing.
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C. It is non-adherent and painless to remove.
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D. It is transparent, allowing for easy wound assessment.

Answer 19

Answer: B. It provides a moist environment that promotes healing.

Rationale: Hydrocolloid dressings create a moist, gel-like environment that is beneficial for healing shallow wounds like stage 2 pressure injuries.

Question 20

Question: A nurse is teaching a patient with a new surgical incision about wound care. What instructions should the nurse include?
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A. Keep the wound covered with a dry dressing.
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B. Wash the wound daily with soap and water.
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C. Apply hydrogen peroxide to the wound to prevent infection.
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D. Report any redness, swelling, or drainage to the healthcare provider.

Answer 20

Answer: D. Report any redness, swelling, or drainage to the healthcare provider.

Rationale: These are signs of possible infection and need prompt medical attention.

Question 21

Question: A nurse is preparing to perform oral care for a patient who is unable to do it themselves. What is the most important principle?
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A. Use a hard-bristled toothbrush to remove plaque effectively.
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B. Encourage the patient to swallow the toothpaste for fluoride protection.
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C. Handle dentures carefully and avoid dropping them.
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D. Use a tongue depressor to retract the cheeks and improve visibility.

Answer 21

Answer: C. Handle dentures carefully and avoid dropping them.

Rationale: Dentures are fragile and costly to replace. Proper handling prevents damage and ensures patient safety.

Question 22

Question: A nurse is caring for a patient who is at risk for falls. What hygiene-related intervention should the nurse prioritize?
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A. Ensuring the call light is within reach.
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B. Providing non-skid footwear.
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C. Keeping the bed in the lowest position.
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D. Using a gait belt when ambulating the patient.

Answer 22

Answer: B. Providing non-skid footwear.

Rationale: While all options are fall-prevention strategies, non-skid footwear directly addresses a hygiene-related fall risk.

Question 23

Question: When performing hand hygiene, what is the recommended duration for scrubbing with soap and water?
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A. 5 seconds
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B. 10 seconds
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C. 20 seconds
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D. 30 seconds

Answer 23

Answer: C. 20 seconds

Rationale: This is the widely accepted standard to effectively remove germs.

Question 24

Question: A nurse is assessing a patient with a Stage 4 pressure ulcer. Which findings would the nurse expect to see with this stage of pressure injury? Select all that apply.
* A. Undermining
* B. Blanching
* C. Pain of 10/10
* D. Sanguineous drainage
* E. Slough
* F. Tunneling
* G. Foul drainage odor
* H. Sutures

Answer 24

Answer: A, D, E, F

Rationale: A stage 4 pressure injury would exhibit undermining (tissue loss under wound edges), sanguineous drainage (bloody), slough (dead tissue), and tunneling (channels extending from the wound).

Question 25

Question: A nurse is caring for a patient who has a history of falls. Which intervention would be most appropriate to include in the patient’s plan of care to prevent future falls related to hygiene?
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A. Provide the patient with a shower chair and grab bars.
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B. Assist the patient with bathing and toileting every 4 hours.
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C. Encourage the patient to wear shoes with good traction.
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D. Assess the patient’s bathroom for potential hazards.

Answer 25

Answer: A. Provide the patient with a shower chair and grab bars.

Rationale: This directly addresses safety during bathing, a common time for falls.

Question 26

Question: What is the primary goal of hygiene care for patients?
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A. To meet regulatory standards for cleanliness.
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B. To prevent the spread of healthcare-associated infections.
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C. To promote patient comfort and well-being.
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D. To reduce the workload for nursing staff.

Answer 26

Answer: C. To promote patient comfort and well-being.

Rationale: While infection control is important, the ultimate goal of hygiene care centers on patient comfort and overall well-being.

Question 27

Question: A nurse is caring for a patient with an open wound. What type of dressing would be most appropriate for a wound with a large amount of exudate?
* A. Gauze dressing
* B. Transparent dressing
* C. Hydrogel dressing
* D. Alginate dressing

Answer 27

D. Alginate dressing

Rationale: Alginate dressings are highly absorbent and designed for wounds with significant drainage.

Question 28

Question: Which factor is most likely to delay wound healing in a patient with diabetes?
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A. Poor circulation
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B. Inadequate protein intake
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C. Frequent wound irrigation
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D. Use of hydrocolloid dressings

Answer 28

Answer: A. Poor circulation

Rationale: Diabetes often leads to vascular complications that impair blood flow to tissues, hindering healing.

Question 29

Question: A nurse is delegating hygiene care to a nursing assistant. What instruction is most critical for the nurse to provide?
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A. “Be sure to use hot water to kill germs.”
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B. “Report any areas of redness or skin breakdown.”
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C. “Encourage the patient to do as much as they can independently.”
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D. “Complete the bath within 30 minutes to avoid tiring the patient.”

Answer 29

Answer: B. “Report any areas of redness or skin breakdown.”

Rationale: Early detection of skin issues is vital, and the nursing assistant plays a key role in observation.

Question 30

Question: A nurse is assessing an older adult patient’s skin and notes that it is thin and dry. What intervention would be most helpful in preventing skin breakdown?
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A. Apply a thick layer of petroleum jelly to the patient’s skin.
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B. Bathe the patient daily with antibacterial soap.
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C. Use gentle, pH-balanced cleansers and moisturizers.
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D. Encourage the patient to wear tight-fitting clothing for support.

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Answer 30

Answer: C. Use gentle, pH-balanced cleansers and moisturizers.

Rationale: Older adult skin is fragile and requires delicate care. Harsh soaps and friction can exacerbate dryness and increase the risk of injury