A nurse assesses clients on a medical-surgical unit.
Which client is at greatest risk for pressure injury development?
A 44 year old prescribed intravenous antibiotics for pneumonia.
A 26 year old who is bedridden with a fractured leg.
A 65 year old with hemiparesis and incontinence.
A 78 year old requiring assistance to ambulate with a walker.
The Correct Answer is C
Choice A rationale
The 44-year-old client with pneumonia receiving intravenous antibiotics is at some risk due to potential immobility and fever, which can lead to diaphoresis and skin maceration. However, this client is likely mobile enough to shift positions independently or with minimal assistance, reducing the risk of sustained pressure. The client's age and general health status, aside from the acute infection, suggest good tissue perfusion and skin integrity.
Choice B rationale
A 26-year-old who is bedridden with a fractured leg is at significant risk due to immobility. The inability to shift weight and relieve pressure on bony prominences can lead to ischemia and tissue damage. However, younger individuals generally have better vascular supply, skin turgor, and faster cellular regeneration compared to older adults, which provides some protective physiological advantage against pressure injury development.
Choice C rationale
This 65-year-old client is at the greatest risk due to a combination of multiple risk factors. Hemiparesis leads to immobility and the inability to reposition, causing prolonged pressure on one side of the body. Incontinence exposes the skin to moisture and chemical irritants from urine and feces, leading to maceration and a breakdown of the skin's protective barrier, making it more susceptible to injury.
Choice D rationale
A 78-year-old requiring a walker for ambulation is at a lower risk for pressure injuries compared to a bedridden individual. Although advanced age and the need for assistive devices suggest some mobility limitations, the ability to ambulate, even with assistance, indicates the capacity to shift weight and relieve pressure on a regular basis. This regular movement promotes circulation and prevents prolonged periods of immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["300"]
Explanation
Step 1 is 300 mL ÷ 60 minutes = 5 mL/min.
Step 2 is 5 mL/min × 60 min/hr = 300 mL/hr. The final answer is 300 mL/hr.
Correct Answer is C
Explanation
Choice A rationale
Tazarotene, a retinoid, increases photosensitivity by thinning the stratum corneum, the skin's outermost layer. This reduces the protective barrier against ultraviolet (UV) radiation, making the skin more susceptible to sunburn and UV-induced DNA damage. Patients must be educated to use sun protection, but it is not the most critical question.
Choice B rationale
While a history of skin cancer can influence dermatological treatment plans, it is not the primary contraindication for tazarotene. Tazarotene is an analog of vitamin A, and its mechanism involves regulating cell proliferation and differentiation, which is not directly related to a personal or family history of skin cancer.
Choice C rationale
Tazarotene is a potent teratogen, meaning it can cause severe congenital malformations if taken during pregnancy. This teratogenic risk necessitates that all female patients of child-bearing potential use reliable contraception to prevent pregnancy. A pregnancy test is also required before initiation of therapy.
Choice D rationale
While some medications interact with alcohol, tazarotene is a topical retinoid primarily metabolized in the liver to its active form, tazarotenic acid. There is no significant systemic absorption or direct interaction with alcohol consumption that would cause a major adverse effect, making it a less critical question than contraception.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.