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 ["B","D","E"]

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

A. Egophony B. normal voice transmission. C. Air filled lungs D. Bronchophony

Correct Answer is A

Explanation

A. Egophony: Egophony is a type of abnormal voice sound transmission where the letter "E" is heard as an "A" when auscultated through a stethoscope. This can indicate underlying lung pathology, such as consolidation or infection, that alters the way sounds are transmitted through the lung tissue.
B. Normal voice transmission: Normal voice transmission would involve hearing the letter "E" clearly and accurately as the patient says it, without distortion. The presence of an "A" sound indicates an abnormal finding, not a normal one.
C. Air-filled lungs: Air-filled lungs typically transmit voice sounds clearly and normally. If the sound changes to an "A," this suggests a pathology that alters sound transmission, rather than indicating simply air-filled lungs.
D. Bronchophony: Bronchophony refers to the increased clarity of spoken sounds heard through the stethoscope over areas of lung consolidation, but it does not specifically describe the transformation of the letter "E" to "A." The specific change in sound transmission described here is characteristic of egophony.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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