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: Avoiding sunscreen is not recommended as it increases the risk of skin cancer; vitamin D can be obtained safely through diet and supplements.

Choice B reason: While it is true that vitamin D and calcium are balanced with phosphorus, this statement does not directly encourage compliance with supplementation.

Choice C reason: Although calcium uses vitamin D produced by sunlight exposure, relying solely on sunshine is not sufficient, especially for individuals at risk of osteoporosis.

Choice D reason: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.

A. Cool and shake the bottle before administering the drops. B. Insert the tip of the dropper into the canal of the ear. C. Pull the pinna up and back to administer the drops. D. Administer the drops with the head held upright.

Correct Answer is C

Explanation

Choice A reason: Cooling the bottle is not necessary and shaking it is only required if the instructions specify to do so to mix the medication.

Choice B reason: Inserting the tip of the dropper into the ear canal is not recommended as it can introduce bacteria and cause injury.

Choice C reason: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.

Choice D reason: Administering the drops with the head held upright is not the correct method; the head should be tilted to allow the drops to flow down into the ear canal.

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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

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

Correct Answer is D

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Correct Answer is C

Explanation

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