A nurse provides care for several clients. Which client is at greatest risk of developing a pressure injury?
An adolescent client with diabetes mellitus who is admitted for hyperglycemia.
A middle-aged adult client who is comatose following a stroke.
An older adult client who is recovering from a sinus infection.
An adult client with a spinal cord injury who engages in daily physical therapy.
The Correct Answer is B
A. An adolescent client with diabetes mellitus who is admitted for hyperglycemia: Diabetes can impair circulation and wound healing, but adolescents are generally mobile and able to reposition independently. Short-term hyperglycemia alone does not create sustained pressure over bony prominences. Mobility significantly reduces pressure injury risk.
B. A middle-aged adult client who is comatose following a stroke: Coma results in complete immobility, loss of protective reflexes, and inability to reposition or perceive discomfort. Prolonged pressure over bony areas compromises tissue perfusion and increases ischemic injury. Neurologic impairment and immobility place this client at the highest risk.
C. An older adult client who is recovering from a sinus infection: Advanced age can increase vulnerability to skin breakdown, but a sinus infection does not typically limit mobility or sensation. Clients who are alert and ambulatory can relieve pressure independently. Risk remains relatively low without immobility.
D. An adult client with a spinal cord injury who engages in daily physical therapy: Although spinal cord injury increases baseline risk due to sensory deficits, regular physical therapy promotes mobility, circulation, and pressure relief. Active repositioning and therapeutic movement reduce prolonged pressure exposure. Consistent mobility lowers overall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client with an abnormal gait who takes an anticonvulsant medication: This client is at increased fall risk due to gait instability and potential medication side effects. However, if the client can request assistance and is cognitively intact, the immediate risk is lower than for clients with impaired judgment.
B. A client with lower extremity weakness and dementia: Dementia impairs judgment, awareness of limitations, and the ability to request help, while lower extremity weakness compromises mobility. This combination places the client at highest immediate risk for unassisted falls, making activation of the bed alarm a priority.
C. A client with visual impairment who calls for assistance when needed: While visual deficits increase fall risk, the client’s ability to recognize limitations and seek help mitigates immediate danger. The fall risk is present but less urgent than for a cognitively impaired client who may attempt to get out of bed unassisted.
D. A client with hypotension who uses a walker to ambulate: Hypotension may cause dizziness, increasing fall risk during ambulation. However, if the client waits for assistance and uses mobility aids appropriately, the risk of unassisted falls is lower than in a client with dementia and mobility weakness.
Correct Answer is A
Explanation
A. Low risk: Using the Fall Risk Screening Tool, the client scores 3 points for a fall in the past year, 0 points for age (56 years), 1 point for urinary frequency (as the client was walking to the bathroom when they tripped), 0 points for a steady gait, and 0 points for mental status. The total score is 4 points, which places the client in the low-risk category (0–5 points).
B. Moderate risk: Moderate risk requires 6–9 points. With a total score of 4, the client does not meet this threshold.
C. High risk: High risk is defined as 10 or more points, well above the client’s total score.
D. Very high risk: The tool does not include a “very high risk” category; the highest category is “high risk” (≥10 points).
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