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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Crohn's disease. Crohn’s disease is a chronic inflammatory bowel disease that affects nutrient absorption, leading to malnutrition. It can cause diarrhea, abdominal pain, and intestinal damage, reducing the body's ability to absorb essential nutrients such as proteins, vitamins, and minerals. Clients may also have anorexia and weight loss due to inflammation and malabsorption.
B. Gastroesophageal reflux. Gastroesophageal reflux disease (GERD) can cause discomfort and lead to dietary modifications, but it does not directly cause severe malnutrition. Clients may avoid certain foods, but overall nutrient absorption remains intact.
C. Cholecystitis. Cholecystitis (inflammation of the gallbladder) primarily affects fat digestion. While clients may experience discomfort with fatty foods, it does not typically lead to widespread malnutrition.
D. Diverticulosis. Diverticulosis is usually asymptomatic and does not impair nutrient absorption. While dietary fiber intake is important to prevent complications like diverticulitis, this condition does not pose a high risk for malnutrition compared to Crohn’s disease.

A. Instruct incentive spirometry use every hour. B. Encourage consumption of protein and vitamin C. C. Apply thromboembolism deterrent stockings (TED). D. Use Petroleum based lotion on legs

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the nutritional status of a group of clients in a long term care facility. Which pathophysiological process poses the highest risk for malnutrition in this population?

Correct Answer is A

Explanation

Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

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 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]

The nurse is developing a workshop on cancer prevention for a group of adults at a wellness fair. Which recommendation should the nurse include in the workshop?

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Which is the function of the keratinocytes, a type of skin cell?

Exhibits

The nurse reviews the client's data.

Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.