A nurse is collecting data on 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
Increased muscle mass
Decreased serum calcium
Decreased circulation
The Correct Answer is D
A. Increased collagen is not a direct risk factor for pressure injuries. Collagen plays a role in wound healing but does not increase the risk of developing pressure ulcers.
B. Increased muscle mass does not increase the risk for pressure injuries. In fact, more muscle mass can help protect against pressure ulcers by distributing weight and pressure more evenly.
C. Decreased serum calcium can contribute to weakened bones and muscle function, but it is not a primary factor in the development of pressure injuries.
D. Decreased circulation is a major risk factor for pressure injuries. Impaired mobility often leads to prolonged pressure on certain areas of the body, reducing blood flow to those areas. This lack of circulation can cause tissue ischemia, leading to pressure injuries.
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Related Questions
Correct Answer is A
Explanation
A. Tremors are a common symptom of hypoglycemia. As the blood glucose level falls below the normal range, the body initiates a stress response that can cause shaking or tremors.
B. Bradycardia is not typically associated with hypoglycemia. In fact, hypoglycemia can cause tachycardia as part of the body's compensatory mechanism to raise blood sugar levels.
C. Decreased appetite is not a direct symptom of hypoglycemia. In fact, a person experiencing low blood sugar may feel hungry and may seek food to correct the condition.
D. Flushed skin is more commonly associated with fever or allergic reactions, not hypoglycemia. Low blood sugar typically causes pale, sweaty skin, not flushed skin.
Correct Answer is C
Explanation
A. Pulmonary embolism is unrelated to dysphagia, and although a client with dysphagia may be at risk for clotting (due to immobility or other factors), it is not the primary complication of dysphagia.
B. Diarrhea can occur in clients receiving enteral nutrition, but it is not a direct complication of dysphagia itself.
C. Pneumonia is the most common and serious complication of dysphagia due to the risk of aspiration. When food or liquids are inhaled into the lungs, they can cause an infection, leading to aspiration pneumonia.
D. Pressure injury is typically related to immobility or prolonged pressure on the skin and is not directly related to dysphagia, though dysphagic clients who are also immobile may be at higher risk for pressure injuries.
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