A nurse is conducting a pressure injury risk assessment on a client. Which of the following findings places the client at the highest risk for skin breakdown?

Has occasional incontinence

Eats one serving of protein per day

Responds to verbal commands

Is able to walk short distances

Answer and Explanation

The Correct Answer is B

A. Has occasional incontinence. Incontinence increases moisture exposure and contributes to skin breakdown risk, but "occasional" incontinence presents a moderate rather than the highest level of risk. Consistent exposure would be more concerning.
B. Eats one serving of protein per day. Inadequate protein intake significantly impairs tissue repair and skin integrity, placing the client at the highest risk for pressure injuries. Protein is essential for maintaining skin health and supporting the healing process.
C. Responds to verbal commands. This indicates that the client is alert and cognitively intact, allowing for active participation in repositioning and care, which lowers the risk for skin breakdown.
D. Is able to walk short distances. Some level of mobility helps relieve pressure and promotes circulation, both of which reduce the likelihood of pressure injury development. Limited mobility presents less risk than poor nutritional intake.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Whole-wheat pasta, green salad, and diet cola: While this meal is low in fat and suitable for hypertension, it lacks a clear protein source. Additionally, diet cola contains caffeine and artificial sweeteners, which some clients may choose to avoid due to personal or health preferences.
B. Broiled chicken, grilled potatoes, and lemonade: This option is appropriate for a client with hypertension and complies with Islamic dietary laws. Chicken is a halal protein, and the meal is low in sodium and saturated fat. Lemonade is a non-caffeinated beverage that aligns with religious and health considerations.
C. Roast beef, brown rice, and coffee: Roast beef is permissible if it is halal, but this cannot be assumed unless specified. Coffee contains caffeine, which some individuals with hypertension may need to limit. The meal also lacks details on fat and sodium content.
D. Grilled pork loin, steamed vegetables, and water: Pork is strictly prohibited (haram) in Islamic dietary laws. Although the vegetables and water are appropriate, the inclusion of pork makes this meal unacceptable for a practicing Muslim.

A. Grapefruit B. Coffee C. Milk D. Oatmeal

Correct Answer is A

Explanation

A. Grapefruit: Grapefruit inhibits the cytochrome P450 3A4 enzyme in the liver, which is responsible for metabolizing atorvastatin. When this enzyme is blocked, the levels of atorvastatin in the blood can rise increasing the risk of serious side effects such as muscle toxicity and liver damage. Clients taking statins should completely avoid grapefruit to ensure the medication is processed safely and effectively.
B. Coffee: Coffee does not interact with atorvastatin in a clinically significant way. While excessive caffeine intake can have other health implications, it does not affect the metabolism or effectiveness of atorvastatin. Clients with hyperlipidemia may still consume coffee in moderation unless otherwise advised based on other health conditions.
C. Milk: Milk does not interfere with atorvastatin's absorption or metabolism. It is safe to consume while on the medication. In fact, low-fat dairy products can be part of a heart-healthy diet aimed at lowering cholesterol, making milk an acceptable food choice for clients with hyperlipidemia.
D. Oatmeal: Oatmeal is beneficial for clients with hyperlipidemia because it contains soluble fiber, which helps to lower LDL (bad) cholesterol levels. There are no known interactions between oatmeal and atorvastatin. Including oatmeal in the diet supports the therapeutic goals of atorvastatin by promoting heart health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is conducting a pressure injury risk assessment on a client. Which of the following findings places the client at the highest risk for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has hypertension with selecting meals. The client reports following Islamic dietary laws. Which of the following is the appropriate menu selection for this client?

Correct Answer is B

Explanation

A nurse is teaching a client who has hyperlipidemia and a new prescription for atorvastatin. The nurse should instruct the client to avoid which of the following foods?

Correct Answer is A

Explanation

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take to reduce the risk for aspiration?

A nurse is assessing a client who has received treatment for hypocalcemia. Which of the following findings indicates the treatment has been effective?

A nurse is teaching a client who reports wanting to lose weight about behavioral modifications. Which of the following statements should the nurse include in the teaching?

A nurse is counseling a client about principles that promote weight loss. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing anticipatory guidance to a client who has phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?

A nurse is preparing to screen a newborn for phenylketonuria. The nurse should inform the parents that this screening allows for early detection and intervention to prevent the development of which of the following conditions?

A nurse is planning to teach a group of clients about heart healthy food choices at a community health fair. Which of the following instructions should the nurse plan to include in the teaching?

A nurse is caring for a client who is receiving chemotherapy treatments. The client states, "I feel so nauseated after my treatments." Which of the following instructions should the nurse provide the client? (Select all that apply.)