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Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Apply a zinc based cream with brief changes

Apply powder to the perineum

Provide a donut shaped pillow to sit on

Use an antimicrobial soap to clean skin

Place a foam pad on the bed

Ensure the client slides up in bed on their own

Two person assist to move up in bed using slide sheet

Elevate the head of bed above 30 degrees

Request a physical therapy consult

Answer and Explanation

Correct Answer : A,E,G,I

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

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Correct Answer is C

Explanation

A. Dry mucosal membranes. While dry mucous membranes can indicate dehydration, they are not a definitive indicator of malnutrition. Malnutrition is assessed through body weight, BMI, and lab values such as albumin and prealbumin.
B. Weight of 227 pounds (103 kg). A high body weight does not indicate malnutrition. Some individuals with obesity can still be malnourished due to poor nutrient intake, but weight alone is not the best diagnostic indicator.
C. Body mass index (BMI) of 17 kg/m². A BMI below 18.5 kg/m² is classified as underweight, and a BMI of 17 kg/m² indicates malnutrition. BMI is a standard measure used to assess nutritional status and underweight conditions.
D. Decrease in the appetite. A decreased appetite (anorexia) can contribute to malnutrition, but it is a symptom, not a definitive diagnostic indicator. Some individuals with poor appetite may still maintain an adequate nutritional status.

A. Dedicated breastfeeding for 6 months. B. Consumption of whole milk as a toddler. C. Introduction of fortified cereal before 4 months of age. D. Exclusive soy based formula for the first year of life.

Correct Answer is C

Explanation

A. Dedicated breastfeeding for 6 months. Exclusive breastfeeding for at least 6 months is recommended by the American Academy of Pediatrics (AAP) and is associated with a lower risk of childhood obesity. Breastfeeding helps regulate appetite and metabolism.
B. Consumption of whole milk as a toddler. Whole milk is recommended from ages 1 to 2 years for brain development and growth. While excessive milk intake may contribute to weight gain, it is not a primary risk factor for early childhood obesity.
C. Introduction of fortified cereal before 4 months of age. Introducing solid foods before 4 months is linked to an increased risk of childhood obesity. Early introduction may disrupt natural hunger and satiety cues, leading to overeating later in life. The AAP recommends introducing solid foods around 6 months of age.
D. Exclusive soy-based formula for the first year of life. Soy-based formula is nutritionally comparable to cow's milk-based formula. While formula feeding in general has been associated with a slightly higher risk of obesity than breastfeeding, soy formula itself is not a direct risk factor for obesity.

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Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? Reference Range: Body mass index (BMI) [18 to 24.9 kg/m3]

Correct Answer is C

Explanation

The nurse is caring for a school age child whose parent reports concern for the child's weight gain and obesity status. Which historical finding should the nurse recognize as potentially contributing to early obesity?

Correct Answer is C

Explanation

The nurse is teaching a health promotion class for adults about the effects of sun exposure on skin. Which statement about the function of collagen is correct?

Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

The nurse is conducting a nutritional class on foods that have been linked to help decrease the development of some forms of cancer. Which meal selection is the best choice to help reduce the risk of some cancers?

Exhibits The nurse reviews the client's data. Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Which test for HIV is used primarily as a confirmatory test rather than a generalized screening test?

Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.