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 A
Explanation
Choice A rationale:
The nurse is demonstrating the concept of disease prevention during a blood pressure screening for a client with a family history of hypertension. Disease prevention involves actions taken to reduce the risk of developing a disease or condition. In this case, the nurse is actively screening for hypertension, a condition that the client may be at risk for due to their family history. By identifying elevated blood pressure early, the nurse can help prevent the progression of hypertension and its associated complications.
Choice B rationale:
Holistic health is a comprehensive approach to healthcare that considers the physical, emotional, social, and spiritual aspects of an individual. While holistic health is an essential aspect of nursing care, the scenario described in the question focuses on a specific action related to blood pressure screening, which is better categorized as disease prevention.
Choice C rationale:
Health promotion involves activities that aim to enhance a person's well-being and quality of life, such as encouraging healthy behaviors and lifestyle choices. While blood pressure screening can be a part of health promotion, the primary goal in the scenario is to identify and prevent hypertension, which aligns more with disease prevention.
Choice D rationale:
Health education refers to the process of providing information and education to individuals to help them make informed decisions about their health. While health education may be a part of the overall nursing care provided to the client, the primary action in the scenario is to perform a blood pressure screening, which is a proactive measure to prevent disease, rather than solely focused on educating the client.
Correct Answer is A
Explanation
Choice A rationale:
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
Choice B rationale:
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
Choice C rationale:
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
Choice D rationale:
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
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