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 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. Instruct the client to lie down after a meal. B. Encourage the client to rest prior to mealtimes. C. Turn on the client's television during meals. D. Place the client into a semi-reclined position for meals.

Correct Answer is B

Explanation

A. Instruct the client to lie down after a meal: Lying down after meals increases the risk of aspiration in clients with difficulty swallowing. It impairs gravity-assisted esophageal emptying and allows food or liquids to reflux, increasing the chance of choking or aspiration pneumonia.
B. Encourage the client to rest prior to mealtimes: Resting before meals conserves the client's energy, allowing them to focus on eating slowly and carefully, which promotes safer swallowing. Fatigue increases the risk of aspiration because muscle coordination during swallowing becomes impaired.
C. Turn on the client's television during meals: Turning on the television is a distraction that can reduce the client’s attention during chewing and swallowing. This lack of focus increases the risk of aspiration or choking, especially in clients with dysphagia.
D. Place the client into a semi-reclined position for meals: A semi-reclined position may hinder proper swallowing mechanics and promote aspiration. Clients with swallowing difficulty should ideally be in an upright 90-degree sitting position to reduce aspiration risk during meals.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

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