A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral ulcer with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

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Correct Answer is A

Explanation

Choice A reason: Understanding the reason for taking aspirin is crucial because it could be for a chronic condition that requires antiplatelet action, which ibuprofen does not provide. Aspirin is often prescribed for its antiplatelet effect to prevent blood clots, while ibuprofen is primarily used for pain and inflammation.

Choice B reason: While the dosage of ibuprofen is important, it is secondary to understanding the purpose of the aspirin therapy. Overdosing on ibuprofen can lead to serious side effects, but the immediate risk of stopping aspirin without a suitable substitute could be more critical.

Choice C reason: Assessing the amount of pain control is important to evaluate the effectiveness of ibuprofen as a substitute for aspirin. However, this does not address the potential risks associated with the cessation of aspirin, especially if it was prescribed for cardiovascular reasons.

Choice D reason: The presence of gastric pain could indicate an adverse reaction to ibuprofen, which is known to cause gastrointestinal issues. However, this information is not as immediately necessary as understanding the reason for aspirin therapy, which could have significant implications for the client's health.

A. Hypothermia. B. Aspiration. C. Falls. D. Suicide.

Correct Answer is C

Explanation

Choice A reason: Hypothermia is not typically associated with hyperparathyroidism and does not require specific precautions in this context.

Choice B reason: Aspiration may be a concern for patients with severe hypercalcemia if they have altered mental status, but it is not the primary safety precaution.

Choice C reason: Falls are a significant risk due to potential muscle weakness, skeletal fragility, and possible neuromuscular symptoms caused by hypercalcemia.

Choice D reason: Suicide is not directly related to hyperparathyroidism; however, mental health should always be monitored in patients with chronic conditions.

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A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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