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 D

Explanation

Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.

Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.

Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.

Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

A. A family member of a client with dementia who has been missing for five hours. B. A client with schizophrenia who wants to stop taking the medications. C. The parent of a child who was involved in a physical fight at school today. D. A client diagnosed with depression who is experiencing sexual dysfunction.

Correct Answer is A

Explanation

Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.

Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.

Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.

Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.

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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

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Correct Answer is A

Explanation

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