A nurse is reviewing the medical history of a client who is scheduled for surgery.
Which of the following findings places the client at risk for an incisional hematoma?

Choice A rationale;

Inability to form healthy relationships: This is more commonly associated with fixation at the phallic stage.

Choice B rationale:

Feelings of shame are associated with Freud's psychosexual stages, particularly during the anal stage. Fixation at the oral stage is more likely to result in issues related to dependency and oral fixation, which may manifest as habits like nail-biting or smoking, rather than feelings of shame.

Choice C rationale:

According to Freud's psychosexual theory, fixation at the oral stage can lead to oral personality traits. These traits are often associated with oral activities like eating, drinking, smoking, and talking. Overeating is a common behavior linked to oral fixation, as it represents a seeking of oral gratification.

Choice D rationale:

Bedwetting is not typically associated with fixation at the oral stage of development. Bedwetting is more commonly linked to issues at the anal stage. In the oral stage, the fixation is primarily related to dependency and oral behaviors. .

Choice A rationale:

The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.

Choice B rationale:

The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.

Choice C rationale:

The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.

Choice D rationale:

The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.