A nurse is caring for several clients. Which of the following clients is most prone to skin infections?
A 60 year old client with gastritis
A 20 year old client with closed tibia fracture
A 55 year old client taking an ACE inhibitor
A 35 year old client receiving chemotherapy
The Correct Answer is D
A. A 60-year-old client with gastritis:
Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.
B. A 20-year-old client with a closed tibia fracture:
A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.
C. A 55-year-old client taking an ACE inhibitor:
ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.
D. A 35-year-old client receiving chemotherapy:
Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stage III pressure injury
Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.
B. Stage IV pressure injury
Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.
C. Stage II pressure injury
Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.
D. Stage I pressure injury
Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.
Correct Answer is A
Explanation
A. Keeping the wound clean and non-infected: When caring for a client with a pressure injury, the priority in the plan of care is to keep the wound clean and prevent infection. This involves regular wound assessment, proper wound cleaning techniques, application of appropriate dressings, and monitoring for signs of infection such as increased redness, swelling, warmth, or drainage. Preventing infection is crucial for promoting healing and preventing complications.
B. Application of a negative pressure wound care device: While negative pressure wound therapy (NPWT) can be beneficial in promoting wound healing, it may not be the immediate priority unless specifically indicated by the healthcare provider based on the stage and characteristics of the pressure injury. Keeping the wound clean and preventing infection take precedence over NPWT in the initial plan of care.
C. Client education on wound prevention: While client education is important for preventing future pressure injuries, it is not the immediate priority when caring for an existing pressure injury. The focus initially should be on managing the current wound to promote healing and prevent complications.
D. Promoting a high carbohydrate, low protein diet: Nutritional interventions are important in wound healing, but promoting a specific diet is not the immediate priority in the plan of care for a pressure injury. Providing adequate nutrition and addressing any nutritional deficiencies may be part of the overall plan, but it is secondary to keeping the wound clean and preventing infection.
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