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.

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Correct Answer is C

Explanation

A. "Make sure to drink water with your meals." While staying hydrated is important for metabolism and satiety, emphasizing water intake with meals over other proven strategies, like portion control and meal timing, may not be the most effective behavioral focus for weight loss education.
B. "Meal replacement shakes can cause weight gain." Stating that meal replacement shakes can cause weight gain can be misleading. Weight gain typically occurs when total caloric intake exceeds expenditure, regardless of whether calories come from shakes or food.
C. "Your biggest meal of the day should be breakfast." Eating a larger breakfast can promote weight loss by jump-starting metabolism and reducing overall calorie intake later in the day. Front-loading calories earlier in the day can improve satiety and energy levels, leading to healthier eating patterns and potentially better adherence to weight loss goals.
D. "Set your weight loss goal to 2.5 pounds per week." A safe and sustainable weight loss goal is typically 1 to 2 pounds per week. A goal of 2.5 pounds per week may be too aggressive and unrealistic for most individuals, increasing the risk of muscle loss, nutritional deficiencies, or rebound weight gain. Encouraging gradual, steady weight loss supports long-term success.

A. The client has a creatinine level of 1.0 mg/dL (0.6 to 1.3 mg/dL). B. The client has a urine output of 35 mL/hr. C. The force of the client's urinary stream has improved. D. The client passes soft, brown stool.

Correct Answer is C

Explanation

A. The client has a creatinine level of 1.0 mg/dL (0.6 to 1.3 mg/dL). A normal creatinine level suggests adequate kidney function but does not directly reflect improvement in urinary flow or lower urinary tract symptoms caused by BPH. It is not a specific indicator of treatment success for this condition.
B. The client has a urine output of 35 mL/hr. This value is at the low end of normal urine output, but it does not confirm improvement in urinary obstruction or symptom relief. Effectiveness of BPH treatment is better assessed through changes in urinary flow and symptom resolution.
C. The force of the client's urinary stream has improved. Improved urinary stream indicates reduced urethral obstruction, which is a primary treatment goal in managing BPH. This finding reflects direct symptom relief and is a clear sign that treatment is effective.
D. The client passes soft, brown stool. Bowel movements are unrelated to the treatment outcomes for benign prostatic hyperplasia. While regular bowel function is important, it does not reflect improvement in urinary symptoms.

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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?

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