Select the closed-ended question below.

Choice A reason: Limited ability to reposition is a major risk factor for pressure injuries, as immobility increases pressure on bony prominences, reducing blood flow and causing tissue ischemia. This leads to skin breakdown, particularly in bedridden patients, making it a critical factor in pressure ulcer development.

Choice B reason: Requiring stand-by assistance for activities of daily living (ADLs) indicates some mobility, as the patient can perform tasks with supervision. This does not inherently increase pressure injury risk, unlike immobility or moisture, making it the least relevant risk factor among the choices.

Choice C reason: Poor nutritional state is a risk factor for pressure injuries, as malnutrition impairs skin integrity and wound healing. Deficiencies in protein or vitamins reduce tissue resilience, increasing susceptibility to pressure-induced damage, particularly in elderly or debilitated patients.

Choice D reason: Moisture from incontinence, wound drainage, or perspiration softens skin, increasing friction and shear forces, which heighten pressure injury risk. It compromises skin barrier function, promoting maceration and ulceration, making it a significant contributor to pressure ulcer formation.

Choice A reason: Percussion involves tapping to assess underlying structures, commonly used for lung or abdominal assessments. In breast assessment, it is not relevant, as it cannot evaluate tissue density or detect masses. Breast examination relies on visual inspection and palpation to identify abnormalities like lumps or skin changes, making percussion inappropriate.

Choice B reason: Inspection is a critical technique in breast assessment, involving visual examination for asymmetry, skin changes, nipple discharge, or dimpling. It precedes palpation to identify visible abnormalities. This method is non-invasive and essential for detecting early signs of breast conditions, such as cancer, aligning with standard clinical protocols for thorough evaluation.

Choice C reason: Doppler ultrasound assesses blood flow, often used in vascular or fetal monitoring, but is not standard for breast assessment. Breast examination uses inspection and palpation, with imaging like mammography for deeper evaluation. Doppler’s role in breast care is limited to specialized diagnostics, not routine physical assessments, making it an incorrect choice.

Choice D reason: Sterile gloves are used for invasive procedures like wound care, not routine breast assessments, which require clean gloves for palpation. Inspection and palpation are primary techniques, and sterile conditions are unnecessary unless performing a biopsy. This choice does not align with standard breast examination practices.