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 D
Explanation
Choice A rationale:
The female urethra is not significantly longer than the male urethra. In fact, it is considerably shorter. The average length of the female urethra is about 4 cm (1.5 inches), while the average length of the male urethra is about 20 cm (8 inches). This difference in length has important implications for catheterization, as it means that the female urethra is more easily accessible and less likely to be damaged during the procedure.
Choice B rationale:
The female urethra does have a distinct anatomy and nerve innervation compared to the male urethra. However, these differences are not as relevant to the process of catheterization as the difference in length. The key anatomical difference to consider is the location of the urethral opening. In females, the urethral opening is located just above the vaginal opening, while in males, it is located at the tip of the penis. This difference in location means that different techniques are required for catheterizing males and females.
Choice C rationale:
The female urethra is connected to the bladder. This is a fundamental anatomical fact that is essential for understanding the process of urination. The urethra is the tube that carries urine from the bladder to the outside of the body. In females, the urethra is also involved in sexual intercourse and childbirth.
Choice D rationale:
This is the correct answer. The female urethra is considerably shorter than the male urethra. This difference in length is important to consider when catheterizing a female patient, as it means that the urethra is more easily accessible and less likely to be damaged during the procedure.
Correct Answer is C
Explanation
Rationale for Choice A:
Making assessments every 15 minutes for four hours does not directly address the immediate concern of blood loss and potential hemodynamic instability. While close monitoring is essential, it's not the primary action in this situation.
Excessive blood loss can rapidly lead to hypovolemic shock, which requires prompt intervention to prevent serious complications.
Relying solely on frequent assessments without active interventions could delay crucial treatment and compromise patient safety.
Rationale for Choice B:
Documenting the data, removing the old dressing, and applying a new dressing might be necessary at some point, but it's not the most urgent priority in this case.
Removing the dressing could disrupt clot formation and potentially worsen bleeding.
Applying a new dressing without addressing the underlying bleeding might not effectively control the blood loss. Rationale for Choice C:
Applying a well-secured additional pressure dressing is the most appropriate immediate action to help control bleeding and prevent further blood loss.
It provides direct compression to the surgical site, promoting hemostasis and reducing blood flow. This action prioritizes stabilizing the patient's condition and preventing further complications.
Reporting the findings to the healthcare provider is crucial for timely assessment, diagnosis, and management of potential complications, such as hemorrhage or hematoma.
It ensures collaboration with the healthcare team and facilitates appropriate interventions based on the patient's specific needs.
Rationale for Choice D:
Reassuring the family that this is a common problem might provide some comfort, but it doesn't address the patient's immediate needs or the potential severity of the situation.
It's essential to prioritize patient safety and provide interventions to control bleeding, even if bleeding is a known potential complication.
Transparency and clear communication with the family are important, but they should not replace necessary medical interventions.
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