A nurse is assessing a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?
Increased collagen.
Decreased circulation.
Increased muscle mass.
Decreased serum calcium.
The Correct Answer is B
Choice A rationale:
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
Choice B rationale:
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
Choice C rationale:
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
Choice D rationale:
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The "Region" in the PQRST mnemonic refers to the location of the pain. It helps identify where the pain is occurring in the body. While this information is important, it does not address the quality or nature of the pain, which is what the nurse is asking the client to describe.
Choice B rationale:
"Severity" in the PQRST mnemonic relates to how intense the pain is. It helps in assessing the degree of pain the client is experiencing, but it does not address the quality or nature of the pain, which is what the nurse is inquiring about.
Choice C rationale:
"Quality" in the PQRST mnemonic pertains to the description of the pain itself. It helps the nurse understand the characteristics of the pain, such as whether it is sharp, dull, burning, throbbing, etc. This information is essential for a more accurate assessment of the pain's underlying cause, making it the correct choice in this scenario.
Choice D rationale:
"Precipitating cause" in the PQRST mnemonic is concerned with what factors or actions might trigger the pain. While this information is valuable, it does not directly address the nature or quality of the pain, which is what the nurse is trying to assess.
Correct Answer is D
Explanation
Choice A rationale:
"Opioid narcotics are restricted for the client because of the risk for addiction.”. This statement is not accurate. Opioid narcotics are not restricted solely due to the risk of addiction. While there is a potential for addiction with opioids, they are still an essential and effective option for managing severe pain, including end-of-life pain. The key is to use them judiciously and monitor for signs of addiction.
Choice B rationale;
"Using opioid narcotics will limit options available for future management of pain.”Using opioids does not limit future pain management options.
Choice C rationale:
"The use of opioid narcotics is restricted to when death is imminent.”. This statement is not accurate either. Opioid narcotics can be used to manage severe pain in various situations, not just when death is imminent. They are not restricted to end-of-life care only.
Choice D rationale:
"The dosage of the opioid narcotic is unlimited.”. The dosage of opioid narcotics can be increased as needed to manage pain effectively. There is no strict limit, and the goal is to provide adequate pain relief.
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