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","D","E"]
Explanation
A. Smoking has been associated with an increased risk of developing osteoarthritis, particularly in the knees and hips. Smoking may contribute to inflammation and oxidative stress, which can exacerbate joint damage.
D. Aging is a significant risk factor for osteoarthritis. As individuals age, the cartilage in their joints may naturally deteriorate over time, leading to the development of osteoarthritis.
E. Obesity is a well-established risk factor for osteoarthritis, particularly in weight-bearing joints such as the knees and hips. Excess body weight places increased stress on the joints, leading to accelerated wear and tear of the joint cartilage.
B. Bacteria are not typically associated with the development of osteoarthritis. Osteoarthritis is primarily a non-inflammatory condition related to wear and tear on the joints rather than an infectious process.
C. Diuretics are medications used to treat conditions such as hypertension and edema by increasing urine output. There is no direct evidence linking diuretic use to the development of osteoarthritis.
Correct Answer is A
Explanation
This description accurately reflects a greenstick fracture. In a greenstick fracture, the bone is partially fractured, typically on one side, while the other side remains intact. It is often compared to the way a green stick bends but does not break completely.

This description is more characteristic of a comminuted fracture, where the bone breaks into multiple fragments that may displace or splinter into the surrounding tissue.

This description is indicative of an impacted fracture, where the bone ends are driven into each other, often due to a compressive force.

This description is characteristic of an open or compound fracture, where the broken bone penetrates the skin and is exposed to the external environment.

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