The nurse is aware that which patients are at risk for a skin alteration?
The patient who had numbness in the right arm that resolved several hours ago.
A patient who has been newly diagnosed with diabetes.
A patient who has had vomiting and diarrhea for several days and lost 12 pounds.
The patient who has paralysis and is unable to move in the bed.
A roofer who spends a lot of time outdoors.
Correct Answer : B,C,D,E
Choice A rationale
While temporary numbness could indicate transient nerve compression, which might rarely predispose to minor skin issues if prolonged or repetitive, it typically resolves without lasting dermatological compromise. Sustained pressure or impaired sensation are the primary risk factors for skin breakdown. This transient event is less likely to lead to a significant skin alteration compared to chronic conditions affecting tissue integrity.
Choice B rationale
Diabetes mellitus impairs microcirculation and peripheral neuropathy, leading to decreased sensation and reduced blood flow to tissues. This compromises the skin's ability to heal and resist infection. Hyperglycemia also weakens collagen and elastin, making the skin more fragile and susceptible to breakdown and delayed wound healing.
Choice C rationale
Significant fluid and electrolyte imbalances due to vomiting and diarrhea, coupled with substantial weight loss, lead to dehydration and malnutrition. Dehydration reduces skin turgor and elasticity, making it more prone to tearing. Malnutrition, particularly protein deficiency, impairs tissue repair and maintenance, increasing susceptibility to skin breakdown.
Choice D rationale
Paralysis prevents independent repositioning, leading to prolonged pressure on bony prominences. This sustained pressure compromises capillary blood flow, resulting in tissue ischemia and necrosis. Without the ability to shift weight, the skin's protective mechanisms are overwhelmed, significantly increasing the risk for pressure injury development.
Choice E rationale
Chronic exposure to ultraviolet (UV) radiation from sunlight, experienced by roofers, causes cumulative damage to dermal collagen and elastin fibers, leading to photoaging. This also increases the risk of basal cell carcinoma, squamous cell carcinoma, and melanoma, which are significant skin alterations including premalignant and malignant lesions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Baclofen is a skeletal muscle relaxant primarily used to alleviate spasticity. It does not have a known pharmacological action that directly stimulates appetite. Appetite regulation is a complex physiological process influenced by various hormones and neurological pathways distinct from baclofen's mechanism of action.
Choice B rationale
Baclofen is a gamma-aminobutyric acid (GABA) mimetic that acts on GABA-B receptors in the spinal cord, inhibiting monosynaptic and polysynaptic reflexes. This action reduces the frequency and severity of muscle spasms and spasticity, which are common and debilitating symptoms in multiple sclerosis.
Choice C rationale
Baclofen is not an antibiotic or an antiseptic, and therefore, it does not reduce the urine bacterial count. Its primary therapeutic effect is on the central nervous system to reduce muscle tone. Urinary tract infections are common in multiple sclerosis due to bladder dysfunction, but baclofen does not directly treat them.
Choice D rationale
While some muscle relaxants can have sedating effects as a side effect, the primary therapeutic goal of baclofen in multiple sclerosis is to relieve muscular spasticity, not to induce sleep. Although it can cause drowsiness, it is not prescribed as a hypnotic or for the sole purpose of promoting sleep.
Correct Answer is B
Explanation
Choice A rationale
While increased fluid intake helps flush bacteria from the urinary tract, encouraging 8 ounces of water every hour could lead to excessive fluid intake (polydipsia) and electrolyte imbalances, specifically hyponatremia, which is not a normal physiological state. A more balanced hydration strategy is generally recommended to prevent urinary tract infections.
Choice B rationale
Proper perineal hygiene, specifically wiping from front to back, is crucial for female patients because it prevents the transfer of fecal bacteria (e.g., Escherichia coli) from the anal region to the urethral opening. The female urethra is short and in close proximity to the anus, making it highly susceptible to ascending bacterial infections without this practice.
Choice C rationale
Using bath powder can introduce foreign particles and potentially irritating substances into the sensitive perineal area, which may disrupt the natural microbial balance and increase the risk of irritation or infection, rather than preventing urinary tract infections. Moisture absorption is better managed through breathable undergarments and good hygiene.
Choice D rationale
Advising patients to hold urine for extended periods can lead to urinary stasis, where urine remains in the bladder for too long, allowing bacteria more time to multiply and ascend the urinary tract. Regular and complete bladder emptying is essential for flushing out potential pathogens and reducing the risk of urinary tract infections.
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