A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

BMI of 20

Peripheral neuropathy

Immobility

Hypoperfusion

Answer and Explanation

Correct Answer : B,C,D

A. BMI of 20: While a BMI of 20 is on the lower end of the normal range, it does not necessarily indicate a high risk for pressure injuries. Extreme low BMI may pose a risk, but a BMI of 20 alone is not a definitive factor in increasing pressure injury risk compared to the other listed conditions.
B. Peripheral neuropathy: Peripheral neuropathy impairs sensation in the skin, which reduces the client’s ability to feel pressure, pain, or discomfort. This diminished sensory perception increases the risk of developing pressure injuries as the client might not be aware of or respond to pressure-related issues.
C. Immobility: Immobility, or limited mobility, significantly raises the risk of pressure injuries because it prevents the client from frequently changing positions. Prolonged pressure on specific body areas can impede blood flow and lead to skin breakdown.
D. Hypoperfusion: Hypoperfusion indicates reduced blood flow to tissues, which can contribute to tissue ischemia and increase the risk of pressure injuries. Inadequate blood flow prevents adequate oxygen and nutrient delivery to the skin, making it more susceptible to damage.

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

Explanation

A) Cerebrovascular disease: Uncontrolled hypertension can lead to cerebrovascular disease, including stroke. High blood pressure damages the blood vessels in the brain, increasing the risk of both ischemic and hemorrhagic strokes. Chronic hypertension contributes to the development of atherosclerosis and can lead to significant cerebrovascular complications.
B) Venous insufficiency: Venous insufficiency is typically associated with conditions that affect the veins, such as chronic venous disease or deep vein thrombosis, rather than hypertension. While hypertension can impact overall cardiovascular health, it is not a primary cause of venous insufficiency.
C) Transient Ischemic Attack (TIA): A TIA, often referred to as a "mini-stroke," is a temporary period of symptoms similar to those of a stroke. Uncontrolled hypertension is a major risk factor for TIAs, as it can cause temporary disruptions in blood flow to the brain, leading to symptoms that resolve within minutes to hours but indicate a higher risk for a full-blown stroke.
D) Left Ventricular Hypertrophy: Left ventricular hypertrophy (LVH) occurs when the heart's left ventricle becomes thickened due to increased pressure workload, commonly from uncontrolled hypertension. This condition can lead to heart failure, arrhythmias, and other cardiovascular problems.
E) Constipation: Constipation is generally not a direct consequence of uncontrolled hypertension. While lifestyle factors such as diet can affect both hypertension and bowel movements, constipation itself is not directly linked to high blood pressure.
F) Bronchitis: Bronchitis, an inflammation of the bronchial tubes, is not directly related to hypertension. It is more commonly associated with smoking, infections, and chronic lung

A. Multiple myeloma B. Cervical cancer C. Ovarian cancer D. Hodgkin's lymphoma

Correct Answer is B

Explanation

A) Multiple myeloma: The HPV vaccine is not related to the prevention of multiple myeloma, which is a type of cancer that affects plasma cells in the bone marrow. Prevention strategies for multiple myeloma focus on managing risk factors, but HPV vaccination is not one of these strategies.
B) Cervical cancer: The HPV vaccine is specifically designed to prevent human papillomavirus (HPV) infection, which is a major risk factor for cervical cancer. By protecting against HPV, the vaccine helps prevent the development of cervical cancer, making it a form of primary prevention for this type of cancer.
C) Ovarian cancer: HPV vaccination is not related to the prevention of ovarian cancer. Ovarian cancer prevention strategies do not include the HPV vaccine, as HPV primarily affects the cervical region and some other genital areas, but not the ovaries.
D) Hodgkin's lymphoma: HPV vaccination is not used to prevent Hodgkin's lymphoma, a type of cancer that affects the lymphatic system. The prevention of Hodgkin's lymphoma typically involves addressing general cancer risk factors and monitoring for early symptoms, but it does not include the HPV vaccine.

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A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

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