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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?

Decreased serum calcium.

Decreased circulation.

Increased collagen.

Increased muscle mass.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreased serum calcium does not directly contribute to pressure injury development.

Choice B rationale:

Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.

Choice C rationale:

Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.

Choice D rationale:

Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

A. Proper nutrition with adequate protein and vitamin C. B. Resting as much as possible and keeping the incisional area still. C. Increasing fluid intake to at least 4000 mL per day. D. Keeping skin and surrounding tissue clean and dry. E. Exercise and deep breathing to increase oxygen.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.

Choice B rationale:

Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.

Choice C rationale:

Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.

Choice D rationale:

Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.

Choice E rationale:

Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D"]

Explanation

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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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?