A nurse is reviewing the medical record of a patient who has a peptic ulcer.
Which of the following findings should the nurse recognize as a risk factor for this condition?

Choice A rationale

While laboratory testing may eventually be necessary to identify the cause of diarrhea, the immediate priority is to gather more information about the patient's condition. Jumping directly to testing without understanding the symptoms could delay appropriate initial interventions and fail to address immediate needs.

Choice B rationale

Assessing the characteristics of the stools, such as frequency, consistency, color, and any associated symptoms like abdominal pain, nausea, vomiting, or fever, is crucial for determining the potential cause and severity of the diarrhea. This information guides subsequent interventions and helps differentiate between self-limiting conditions and those requiring further investigation.

Choice C rationale

Advising the use of loperamide without a proper assessment could mask underlying issues, potentially delaying appropriate treatment if the diarrhea is due to an infection or other serious condition. Antidiarrheal medications are not always indicated and should be used cautiously.

Choice D rationale

While maintaining hydration and electrolyte balance is important, especially with diarrhea, it is not the first action a nurse should take before understanding the nature of the patient's symptoms. The initial step should be to gather more information to guide appropriate advice and interventions.

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.