A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?

A decreased ability to communicate.

Thinning of the skin with loss of elasticity.

A 16 percent increase in overall body fat.

Calcium loss in the bones.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Thinning of the skin with loss of elasticity.

Choice A rationale:

While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:

Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.

Choice C rationale:

A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.

Choice D rationale:

Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.

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Correct Answer is C

Explanation

The correct answer is C. Oriented to person only.

Choice A rationale:

A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.

Choice B rationale:

An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.

Choice C rationale:

Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.

Choice D rationale:

A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.

: 1

A. Oﬀer the client a prescribed sleep medication. B. Reposition the client and provide a back rub. C. Administer an as-needed (PRN) prescription for pain. D. Provide a cup of hot chocolate at bedtime.

Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Oﬀering the client a prescribed sleep medication is not the best initial intervention because it may have side eﬀects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caﬀeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caﬀeinated beverages to the client before bedtime.

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A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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