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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 C

Explanation

A. Obtain at least 8 to 10 hours of sleep per night. Adequate sleep is important for overall health, but it is not a primary recommendation for cancer prevention. There is some evidence linking sleep disturbances to cancer risk, but maintaining a healthy weight and exercising have stronger associations with cancer prevention.
B. Refrain from alcohol. Limiting alcohol intake is recommended, but complete abstinence is not necessary for everyone. Moderate alcohol consumption is associated with an increased risk of certain cancers (e.g., breast, liver, esophageal), but maintaining a healthy weight and exercising have broader, more significant cancer prevention benefits.
C. Maintain a healthy weight and exercise regularly. Obesity and a sedentary lifestyle are major risk factors for multiple types of cancer, including breast, colon, and endometrial cancer. Regular physical activity reduces inflammation, improves immune function, and regulates hormones, all of which lower cancer risk.
D. Know the four warning signs of cancer. While recognizing cancer warning signs is important for early detection, prevention strategies are more effective in reducing overall cancer risk. There is no universally agreed-upon list of "four" warning signs, as different cancers present with different symptoms.

A. Thyroxine (T4). B. Growth hormone (GH) levels. C. Follicle stimulating hormone (FSH) levels. D. Luteinizing hormone (LH) levels.

Correct Answer is A

Explanation

A. Thyroxine (T4). Congenital hypothyroidism is diagnosed by measuring low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). Infants with hypothyroidism have delayed metabolism, poor growth, and developmental delays. Reporting low T4 levels is critical for early treatment with levothyroxine to prevent intellectual disability and growth impairment.
B. Growth hormone (GH) levels. While GH is important for growth, it is not the primary diagnostic test for congenital hypothyroidism. GH deficiency is a separate endocrine disorder.
C. Follicle-stimulating hormone (FSH) levels. FSH is involved in reproductive development and is not relevant for diagnosing hypothyroidism in an infant.
D. Luteinizing hormone (LH) levels. LH plays a role in pubertal development and reproductive function, but it is not used to diagnose congenital hypothyroidism.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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.

Exhibits

The nurse reviews the client's data.

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