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 D

Explanation

A. While abnormal bronchial breath sounds can indicate underlying pathology, they are not typically considered immediately life-threatening.
B. Wheezing is a common symptom of asthma and other conditions that cause airway narrowing. While it can be uncomfortable and distressing, it is not typically considered a life-threatening emergency.
C. Absent breath sounds can indicate a collapsed lung or other serious respiratory condition. However, it is not as immediately life-threatening as stridor, which indicates a severe airway obstruction.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway (larynx or trachea). It is often associated with conditions like croup, epiglottitis, or an allergic reaction leading to airway swelling. Stridor indicates a significant obstruction in the upper airway that can rapidly lead to severe respiratory distress or compromise.

A. Lying supine with arms at the sides. B. Sitting with the hands pushing into the hips. C. Lying supine with one arm elevated over her head. D. Learning forward with hands outstretched.

Correct Answer is C

Explanation

A. This position is useful for inspecting the overall shape and size of the breasts, but it may not be the best for detecting retractions.
B. This position can help identify changes in the breast tissue, but it may not be as effective as raising one arm overhead for detecting retractions.
C. Raising one arm over the head tenses the muscles in the breast and chest, which can make any retractions more visible. Retraction is often characterized by dimpling or pulling of the skin, which may be more noticeable when the breast tissue is taut.
D. This position can be helpful for examining the breasts for other abnormalities, but it may not be the best for detecting retractions.

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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

Which assessment finding is most likely to be immediately life-threatening?

Correct Answer is D

Explanation

You are performing a breast exam on an adult woman. You are inspecting the breasts for signs of retraction. What is the best position to observe for this?

Correct Answer is C

Explanation

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