The nurse is caring for 4 clients. Which client is at highest risk for skin breakdown?

25 year-old with left arm sling

72 year-old with incontinence and dementia

82 year-old with an ankle fracture

45 year-old post total hysterectomy

Answer and Explanation

The Correct Answer is B

A.   Although this client has an arm sling, which could potentially limit movement and cause some localized pressure, they are generally at a lower risk for widespread skin breakdown compared to older adults. Their younger age and lack of other risk factors make them less susceptible overall.
B.   Older adults have thinner skin and decreased elasticity, making them more susceptible to pressure ulcers and skin breakdown. Frequent exposure to moisture from urine or feces can lead to skin irritation and breakdown, especially in areas where skin is already compromised.
C.   While an elderly individual with an ankle fracture is at risk for skin breakdown, especially if immobilized and in a cast, this risk is somewhat less immediate compared to someone with incontinence.
D.   This client is recovering from surgery, which could include temporary changes in mobility or activity levels. However, they are younger and do not have the additional complicating factors like incontinence or dementia. While there is some risk of skin issues post-surgery, it is not as high as the risk posed by incontinence and cognitive impairment in an elderly client.

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Correct Answer is B

Explanation

A. While mammograms are commonly used to evaluate breast tissue in women, they are not typically used for men. In men, gynecomastia is usually evaluated with a physical exam and sometimes ultrasound rather than mammography. A mammogram might be ordered if there is a suspicion of breast cancer, but this is less common and not the first step in evaluating gynecomastia.
B. This is a prudent and effective next step. Certain medications can cause gynecomastia as a side effect, including some antipsychotics, antidepressants, antiandrogens, and calcium channel blockers. Reviewing the medication list can help identify if the gynecomastia might be related to a drug the client is taking.
C. A breast biopsy is an invasive procedure used to diagnose breast cancer or other conditions when there is a concern about a mass or abnormality. If gynecomastia is the only finding and there are no concerning features such as a palpable mass or other symptoms, a breast biopsy would not be the first step.
D. While gynecomastia can occur as a normal part of aging, especially in older men due to hormonal changes, it is important to evaluate it thoroughly to rule out other causes. Simply dismissing it as a normal part of aging without further investigation might overlook an underlying condition or medication side effect.

A. Inguinal nodes. B. Subclavicular nodes. C. Median lymphatic vessel D. Ulnar lymphatic vessel

Correct Answer is B

Explanation

A. The inguinal nodes are located in the groin area. They are not typically assessed when evaluating breast lymph nodes. Instead, these nodes are relevant for assessing the lymphatic drainage of the lower extremities and pelvic region, not the breast.
B. The subclavicular nodes are located just below the clavicle (collarbone). These nodes are part of the lymphatic drainage system for the breast and are important to assess during a breast examination, especially in the context of breast cancer or other breast conditions. Palpating the subclavicular lymph nodes helps evaluate whether cancer has spread beyond the breast tissue.
C. The median lymphatic vessel is not a recognized term in standard lymphatic anatomy. Lymphatic vessels are not typically palpated; rather, lymph nodes are assessed. The median term might refer to the midline of the body but does not pertain to a specific lymph node group relevant to breast assessment.
D. The ulnar lymphatic vessels are related to the lymphatic drainage of the arm, specifically along the ulnar aspect (inner side) of the forearm. These are not relevant to the breast lymph nodes. Assessment of the breast involves checking nodes in the axillary, supraclavicular, and subclavicular regions, not the ulnar lymphatic vessels.

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The nurse is caring for 4 clients. Which client is at highest risk for skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an examination of a 57-year old man, you note gynecomastia. Your next best action is what?

Correct Answer is B

Explanation

In assessing the lymph nodes of the client's breast, which lymph node will the nurse palpate?

Correct Answer is B

Explanation

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