A nurse is providing care for four 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 has protein calorie malnutrition
A client who has type1 diabetes mellitus and is hyperglycemic
A client who has right-sided heart failure and 4+ edema to the lower extremities
A client who has postoperative delirium
A client who is ambulatory following a cardiac catheterization 4 hr ago
Correct Answer : A
A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.
B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.
C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.
D. A client with postoperative delirium is not necessarily at risk of delirium.
E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Checking capillary refill distal to the cast helps assess peripheral circulation and nerve function. A decrease in capillary refill time or other signs of compromised circulation (such as coolness, pallor, or numbness) could indicate a complication like compartment syndrome, which requires immediate intervention.
B. Performing range of motion exercises is important for promoting joint mobility and preventing stiffness, but it is not the priority immediately after the cast application.
C. Educating the client about cast care is important for promoting healing and preventing complications, but it is not the priority immediately after the cast application.
D. Managing pain is important for the client's comfort and well-being, but it is not the priority immediately after the cast application.
Correct Answer is D
Explanation
D. Excessive thyroid hormone replacement therapy, leading to hyperthyroidism, can accelerate bone turnover and increase the risk of osteoporosis. Hyperthyroidism can disrupt normal bone remodeling processes, leading to decreased bone mineral density and increased fracture risk.
A. NSAIDs are commonly used to reduce inflammation and relieve pain. While short-term or occasional use of NSAIDs is generally safe, long-term use or high doses of NSAIDs may be associated with an increased risk of osteoporosis and bone fractures.
B. Anticoagulants, such as warfarin and heparin, are medications used to prevent blood clot formation. While anticoagulants themselves are not directly associated with osteoporosis risk, prolonged immobilization due to conditions requiring anticoagulation therapy (such as deep vein thrombosis or pulmonary embolism) can increase the risk of osteoporosis and bone loss due to decreased weight- bearing activity.
C. Cardiac glycosides, such as digoxin, are medications used to treat heart failure and certain cardiac arrhythmias. There is no direct evidence to suggest that cardiac glycosides themselves are a risk factor for osteoporosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.