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 D

Explanation

A. Angioedema: Angioedema is characterized by deep swelling of the skin and mucous membranes, often caused by allergic reactions. It usually affects areas like the lips, eyes, or throat but does not typically present with vesicular eruptions.
B. Actinic cheilitis: Actinic cheilitis results from chronic sun exposure leading to changes in the lips' texture and color. It typically presents as dry, scaly patches or discoloration, not vesicular eruptions.
C. Angular cheilitis: Angular cheilitis involves inflammation and cracking at the corners of the mouth, often due to fungal or bacterial infection. It does not typically present with vesicular eruptions.

D. Herpes simplex: Herpes simplex virus commonly causes vesicular eruptions on the lips and surrounding skin, known as cold sores or fever blisters. These eruptions are characteristic of the herpes simplex infection and align with the description of vesicular eruptions observed in the client.

A. lateralization of the sound/vibration to both ears equally B. lateralization of the sound/vibration to the left ear. C. bone conduction(BC) is greater than air conduction (AC) D. lateralization of the sound/vibration to the right ear.

Correct Answer is B

Explanation

A) Lateralization of the sound/vibration to both ears equally: The Weber test is used to assess unilateral hearing loss and would not show equal lateralization in the presence of unilateral sensorineural hearing loss. Equal lateralization would suggest normal hearing or symmetrical hearing loss, which is not the case here.
B) Lateralization of the sound/vibration to the left ear: In sensorineural hearing loss, sound is perceived to lateralize to the unaffected ear. Therefore, with right ear sensorineural hearing loss, the sound will lateralize to the left ear, indicating that the left ear has better hearing capability.
C) Bone conduction (BC) is greater than air conduction (AC): This finding is characteristic of conductive hearing loss, not sensorineural hearing loss. In sensorineural hearing loss, air conduction is typically greater than or equal to bone conduction, but the Weber test focuses on lateralization rather than BC versus AC.
D) Lateralization of the sound/vibration to the right ear: If the sound were to lateralize to the affected ear in sensorineural hearing loss, it would suggest that the affected ear is hearing better, which contradicts the nature of sensorineural hearing loss. The sound will actually lateralize to the better-hearing, unaffected ear.

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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

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?

Correct Answer is D

Explanation

A patient came with a right ear sensorineural hearing loss. What should the nurse expect while performing the Weber test?

Correct Answer is B

Explanation

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