A nurse is providing care for clients on a medical-surgical unit.
Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)
A client who is ambulatory following a cardiac catheterization 4 hours ago.
A client who has postoperative delirium.
A client who has protein-calorie malnutrition.
A client who has right-sided heart failure and 4+ edema to the lower extremities.
A client who has type 1 diabetes mellitus and is hyperglycemic.
Correct Answer : B,C,D
Choice A rationale
A client who is ambulatory following a cardiac catheterization 4 hours ago has increased mobility, which reduces the risk of prolonged pressure on bony prominences. The short duration post-procedure and ability to ambulate make this client less susceptible to pressure ulcer development.
Choice B rationale
Postoperative delirium can lead to decreased mobility, increased agitation and friction against surfaces, and impaired ability to communicate discomfort or reposition themselves. These factors significantly increase the risk of prolonged pressure and subsequent pressure ulcer formation.
Choice C rationale
Protein-calorie malnutrition results in decreased subcutaneous tissue and muscle mass, which normally provide cushioning over bony prominences. Poor nutritional status also impairs tissue repair and increases skin fragility, making the client highly susceptible to pressure ulcer development.
Choice D rationale
Right-sided heart failure can cause fluid overload and peripheral edema, particularly in the lower extremities. This edema increases tissue fragility and reduces blood flow to the skin, making it more susceptible to breakdown and pressure ulcer formation, especially in areas with bony prominences like heels and ankles.
Choice E rationale
While hyperglycemia in type 1 diabetes mellitus can impair wound healing and increase the risk of infection if a pressure ulcer develops, it is not a direct primary risk factor for the initial development of pressure ulcers. Immobility, malnutrition, and edema are more direct contributors to skin breakdown due to pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A 24-hour urinary output of 380 mL falls below the generally accepted threshold for oliguria in adults. This reduced output could indicate kidney dysfunction or decreased renal perfusion following surgery.
Choice B rationale
A 24-hour urinary output of 600 mL is within the low end of the normal range for adult urinary output, which is generally considered to be 800 mL to 2000 mL per 24 hours.
Choice C rationale
A 24-hour urinary output of 550 mL is also within the low end of the normal range for adult urinary output. While lower than average, it does not meet the criteria for oliguria.
Choice D rationale
A 24-hour urinary output of 720 mL is within the normal range for adult urinary output and does not indicate oliguria.
Correct Answer is D
Explanation
Choice A rationale
Echinacea is an herb often used to support the immune system, particularly for colds and flu. There is no strong scientific evidence to support its effectiveness in managing the joint pain associated with osteoarthritis, which is a degenerative joint disease.
Choice B rationale
Applying ice to a joint before exercising can decrease pain and inflammation, but it can also stiffen the joint and potentially limit range of motion during activity. Heat application is generally recommended before exercise in osteoarthritis to warm up the muscles and tissues.
Choice C rationale
Purines are compounds that break down into uric acid. Reducing purine intake is important for managing gout, a type of inflammatory arthritis caused by the deposition of uric acid crystals in the joints, not osteoarthritis, which is characterized by cartilage breakdown.
Choice D rationale
Maintaining a recommended body weight is crucial for managing osteoarthritis. Excess weight puts additional stress on weight-bearing joints like the hips and knees, accelerating cartilage breakdown and increasing pain. Weight loss can significantly reduce these stresses and alleviate symptoms.
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