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 "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

The P wave is the first deflection of the ECG complex, preceding the QRS complex. It is typically a small, rounded, and positive deflection on the ECG.

A. Keep the pace of the history moving forward to reduce time. B. Limit the use of brief screening tools C. Limit open-ended questions. D. Have the room well-lit with minimal background noise.

Correct Answer is D

Explanation

(A) Keep the pace of the history moving forward to reduce time: While it's important to be efficient, rushing through the health history can compromise the quality of the information gathered. Older adults may need more time to recall details and respond thoughtfully. Ensuring a thorough and patient approach is essential for obtaining accurate and comprehensive information.
(B) Limit the use of brief screening tools: Brief screening tools can be valuable for identifying specific health issues quickly and efficiently. Limiting their use might lead to missing important information or failing to detect underlying conditions. Using appropriate screening tools helps in capturing relevant data and providing a better overall assessment.
(C) Limit open-ended questions: Open-ended questions are crucial in obtaining detailed and descriptive responses from older adults. Limiting their use could hinder the ability to understand the client’s complete health history and concerns. These questions encourage clients to elaborate on their experiences and provide more nuanced information.
(D) Have the room well-lit with minimal background noise: A well-lit room with minimal background noise creates an environment conducive to effective communication. Older adults might have impaired vision or hearing, so ensuring good lighting and reducing distractions helps them focus and respond more accurately. This strategy enhances the accuracy of the health history and facilitates better interaction between the nurse and client.

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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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Correct Answer is "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

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Correct Answer is D

Explanation

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