A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Hgb 18 g/dL (12 to 16 g/dl)

WBC 12.000/mm3 (5,000 to 10,000/mm3)

25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)

Albumin 3.1 g/dL (3.5 to 5 g/dL)

Answer and Explanation

The Correct Answer is D

Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.

Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.

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Correct Answer is B

Explanation

B. The client's PPD skin test result of 12 mm induration is considered positive for individuals who are at increased risk of tuberculosis, such as those with recent exposure to tuberculosis or immunocompromised individuals. A positive PPD result typically requires follow-up with a healthcare provider for further evaluation, which may include chest X-rays, sputum cultures, and treatment for latent tuberculosis infection if indicated.
A. Annual PPD testing may be indicated for certain populations, such as healthcare workers or individuals at high risk of exposure to tuberculosis. However, the decision to repeat the PPD test annually should be based on individual risk factors and healthcare provider recommendations.
C. The PPD skin test is typically read 48-72 hours after administration to assess for induration.
D. A PPD skin test result of 12 mm induration is considered positive for individuals at increased risk of tuberculosis, but it does not necessarily indicate that the test needs to be repeated immediately.

A. Ensure the client's bed is positioned to greater than 45°. B. Initiate airborne precautions. C. Ensure lights are dimmed in the client's room. D. Encourage frequent ambulation.

Correct Answer is C

Explanation

A. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure.
B. Bacterial meningitis is transmitted through hematogenous route and airborne precautions are not always necessary.
C. Clients with meningitis may be sensitive to light, dimming the lights should be implemented to increase comfort by reducing stimuli.
D. Encourage frequent ambulation is not appropriate for bacterial

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A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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