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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. 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.

A. Hyperpigmented areas that vary in form and color and are slightly elevated from the skin. B. Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags. C. Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees. D. Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back.

Correct Answer is D

Explanation

A. Hyperpigmented areas that vary in form and color and are slightly elevated from the skin
These findings are characteristic of skin conditions such as lentigines or melanocytic nevi rather than acne vulgaris. Acne typically presents with inflammatory and non-inflammatory lesions, not hyperpigmented patches of varying color and elevation.
B. Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags
Skin tags, also known as acrochordons, are benign growths that develop in areas of skin friction. They are not associated with acne vulgaris, which primarily affects the sebaceous glands and hair follicles.
C. Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees
These findings are typical of psoriasis, a chronic autoimmune skin condition. Acne vulgaris does not present with silvery scaling plaques or well-defined erythematous lesions in these locations.
D. Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back
Acne vulgaris results from increased sebum production, follicular hyperkeratinization, bacterial overgrowth, and inflammation. It commonly presents with comedones (blackheads and whiteheads), inflammatory papules, pustules, and sometimes nodules, predominantly affecting the face, neck, chest, and upper back.

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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 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 caring for a young adult who reports uncontrolled acne vulgaris. Which pathological findings should the nurse observe on inspection of skin areas commonly affected in acne vulgaris?

Correct Answer is D

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.