Exhibits
The nurse reviews the client's data.
Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.
Immobility
Obesity
Inadequate nutritional intake
Incontinence
Decreased sensory perception
Coarse lung sounds
Diabetes mellitus
Correct Answer : A,B,C,D,E,G
A. Immobility. The client requires a walker for mobility and reports difficulty repositioning in bed. Limited mobility increases the risk of pressure injuries due to prolonged pressure on certain areas, reducing blood flow and oxygen delivery to the skin.
B. Obesity. The client has a history of moderate obesity, which increases skin friction, moisture retention, and difficulty with self-care. Excess weight places additional pressure on bony prominences, elevating the risk of pressure ulcers.
C. Inadequate nutritional intake. The client has a poor appetite and decreased oral intake, which can lead to protein and nutrient deficiencies. Poor nutrition impairs skin integrity and delays wound healing, further increasing the risk of pressure injuries.
D. Incontinence. The client wears an incontinence brief due to occasional urinary and fecal accidents. Constant exposure to moisture from urine and stool can break down the skin barrier, making it more susceptible to infections and pressure injuries.
E. Decreased sensory perception. The client reports neuropathy in both hands and lower legs, reducing sensation. Impaired sensation can prevent the recognition of pressure, pain, or injury, leading to delayed intervention and increased risk of skin breakdown.
F. Coarse lung sounds. While coarse lung sounds may indicate respiratory congestion or infection, they do not directly contribute to skin injury risk. This factor is less relevant compared to others affecting skin integrity.
G. Diabetes mellitus. The client has poorly controlled type 1 diabetes, which impairs circulation and delays wound healing. Chronic hyperglycemia can lead to reduced immune response and increased susceptibility to infections and pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Immediate allergic reaction mediated by sensitized mast cells. This describes a Type I hypersensitivity reaction, which is an immediate allergic reaction. It involves IgE antibodies and mast cell degranulation, leading to symptoms such as hives, anaphylaxis, and respiratory distress. Latex allergies can involve Type I reactions, but delayed hypersensitivity is a Type IV reaction.
B. Antigen-antibody complexes deposit in tissues activating inflammation. This describes a Type III hypersensitivity reaction, which involves immune complex deposition leading to inflammation, as seen in lupus or serum sickness. Latex allergies do not involve immune complex deposition.
C. T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction. This describes a Type IV hypersensitivity reaction, which is a delayed-type hypersensitivity (DTH) mediated by T-cells rather than antibodies. In latex-induced delayed hypersensitivity, T-cells recognize latex proteins and release cytokines, leading to localized skin inflammation, rash, and itching, typically 24–48 hours after exposure.
D. Antibodies are formed against antigens on cell surfaces. This describes a Type II hypersensitivity reaction, which involves antibody-mediated destruction of cells, as seen in hemolytic anemia or blood transfusion reactions. Latex allergies do not involve direct antibody attack on cells.
Correct Answer is A
Explanation
A. It is the main structural component of the dermis which provides strength and elasticity. Collagen is the primary protein in the dermis, responsible for maintaining skin strength, firmness, and elasticity. Sun exposure damages collagen fibers, leading to wrinkles, sagging skin, and premature aging.
B. It increases skin elasticity with the aging process. Collagen production decreases with age, leading to reduced skin elasticity and increased wrinkle formation. Sun damage accelerates this process by breaking down collagen fibers.
C. It forms the ridges and valleys which provide traction for grasping objects and surfaces. Friction ridges (fingerprints) are formed by the dermal papillae, not collagen. They provide grip and are genetically determined.
D. It is an extensive network of blood vessels that regulates body temperature. The dermis contains a network of blood vessels for temperature regulation, but this function is not related to collagen. Instead, collagen provides structural support to the skin.
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