A registered nurse working in a long-term care facility is assessing residents at risk for the development of pressure ulcers.
Which one would be most at risk?
A female client, 86 years of age, who is bed-bound
A male client, 75 years of age, who uses a cane
A female client, 92 years of age, who uses a walker
A male client, 83 years of age, who is mobile
The Correct Answer is A
Choice A rationale:
Immobility: A bed-bound client is at the highest risk for pressure ulcer development due to prolonged pressure on bony prominences. The lack of movement prevents adequate blood flow to the tissues, leading to ischemia and tissue breakdown.
Age: Older adults have thinner, more fragile skin that is more susceptible to injury. They also have decreased subcutaneous fat, which provides less cushioning for bony prominences.
Nutritional status: Malnutrition is a significant risk factor for pressure ulcers, as it impairs wound healing and tissue repair. Incontinence: Urinary and fecal incontinence can irritate the skin and increase the risk of breakdown.
Chronic medical conditions: Many chronic medical conditions, such as diabetes, peripheral vascular disease, and neurological disorders, can impair blood flow and sensation, further increasing the risk of pressure ulcers.
Choice B rationale:
Mobility: A client who uses a cane is still able to ambulate, which helps to redistribute pressure and reduce the risk of pressure ulcers.
Age: While a 75-year-old client is still considered an older adult, they are less likely to be at risk than a bed-bound client.
Choice C rationale:
Mobility: A client who uses a walker is able to ambulate, although their mobility may be limited. This still helps to reduce the risk of pressure ulcers compared to a bed-bound client.
Age: A 92-year-old client is at a higher risk due to their age, but their mobility helps to mitigate this risk. Choice D rationale:
Mobility: A mobile client is at the lowest risk for pressure ulcer development, as they are able to frequently reposition themselves and relieve pressure on bony prominences.
Age: While an 83-year-old client is still considered an older adult, their mobility significantly reduces their risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Brown or black urine is not a typical observation associated with Levodopa use. It can indicate other potential causes, such as: Dehydration
Liver disease
Rhabdomyolysis (muscle breakdown)
Certain medications like metronidazole or iron supplements
Hematuria (blood in the urine)
It's essential to rule out these conditions if brown or black urine is observed.
Choice C rationale:
Green or blue-green urine is also not common with Levodopa. It can be caused by:
Medications like amitriptyline, indomethacin, propofol, or methylene blue
Certain food dyes
Urinary tract infections caused by Pseudomonas bacteria
Familial benign hypercalcemia (a rare genetic condition)
Choice D rationale:
Blood-tinged urine (hematuria) is not a direct effect of Levodopa. It can signal underlying urinary tract issues, such as: Infections
Kidney stones
Bladder or kidney tumors
Trauma to the urinary tract
Strenuous exercise
Choice B rationale:
Orange or orange-red urine is the most common observation in patients taking Levodopa. This discoloration is due to: Breakdown of Levodopa into dopamine and other metabolites
These metabolites can impart an orange or reddish hue to the urine
The color intensity may vary depending on dosage and individual metabolism
It's generally harmless and doesn't require medical intervention
However, it's essential to inform healthcare providers about any urine color changes to ensure proper monitoring and rule out other potential causes.
Correct Answer is C
Explanation
Choice A rationale:
While elevating the head of the bed can make it easier to visualize the patient's face and upper chest, it's not the primary rationale for positioning a patient with pneumonia in semi-Fowler's position.
Skin color and temperature can be assessed in other positions as well, such as supine or side-lying. In cases of pneumonia, prioritizing respiratory function takes precedence over ease of skin assessment. Choice B rationale:
While semi-Fowler's position can offer some comfort, it's not the most comfortable position for all patients, especially those with thoracic pain.
Positions that fully support the back and minimize pressure on the chest, such as side-lying with pillows, may provide better pain relief.
The primary goal in positioning a patient with pneumonia is to optimize respiratory function, not solely to maximize comfort.
Choice C rationale:
Semi-Fowler's position effectively promotes lung expansion due to the following reasons:
Gravity: Elevating the head of the bed allows gravity to assist in pulling the diaphragm downward, creating more space for lung expansion.
Abdominal pressure: The semi-upright position reduces pressure from the abdominal organs on the diaphragm, further facilitating its downward movement and enhancing lung expansion.
Secretion drainage: The inclined position encourages drainage of secretions from the upper airways, preventing their accumulation and potential airway obstruction. This allows for better air entry and gas exchange.
Choice D rationale:
While semi-Fowler's position may slightly increase venous return to the heart, it's not the primary reason for using this position in patients with pneumonia.
Positions that significantly increase venous return, such as Trendelenburg position (head down), are typically used for specific indications like shock or hypotension, not for pneumonia management.
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