A nurse is caring for a group of clients.
Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?
A client who is unresponsive to verbal commands and changes position occasionally.
A client who is alert and responsive and eats 25% of each meal.
A client who is receiving enteral feeding and can change position independently.
A client who makes frequent slight changes in position and walks occasionally.
The Correct Answer is A
Choice A rationale:
The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.
Choice B rationale:
The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.
Choice C rationale:
The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.
Choice D rationale:
The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.
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:
Spirituality can increase feelings of hopelessness. This statement is not accurate. In many cases, spirituality can provide comfort, support, and a sense of hope for individuals who are nearing the end of life. Many people turn to their faith and spirituality as a source of strength and consolation during difficult times.
Choice B rationale:
Spirituality can increase the desire to hasten death. This statement is not generally true. Spirituality often has the opposite effect by providing a sense of purpose and meaning in life, which can help individuals find reasons to continue living. While some individuals may grapple with complex feelings related to death, it's not a typical outcome of embracing spirituality.
Choice C rationale:
Spirituality can increase depression. This statement is not accurate. Spirituality can actually serve as a source of emotional support and resilience for individuals facing the end of life. It can help individuals cope with their emotions and provide a sense of peace and comfort.
Choice D rationale:
Spirituality can increase the quality of life. This statement is correct. Spirituality often plays a positive role in the lives of individuals nearing the end of life. It can enhance the quality of life by providing emotional and psychological support, promoting a sense of purpose, and helping individuals find comfort and peace during this challenging time.
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