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. Often referred to as "pigeon chest," pectus carinatum is a condition where the chest protrudes outward. This deformity makes the chest appear to bulge forward, giving it a distinctive "pigeon-like" appearance.
B. Barrel chest is characterized by an increased anteroposterior (AP) diameter of the chest, giving it a rounded, barrel-like appearance. This can occur due to conditions such as chronic obstructive pulmonary disease (COPD) or emphysema.
C. Scoliosis is a lateral curvature of the spine, which can cause a noticeable asymmetry in the rib cage and back. It often presents as a side-to-side curve in the spine, which can lead to an uneven shoulder height and a visibly curved back when viewed from the side.
D. Known as "funnel chest," pectus excavatum is a condition where the breastbone (sternum) is sunken into the chest. This causes a noticeable depression in the middle of the chest and may appear as a concave or hollowed area.

A. Cyclic pain B. Noncyclic C. Fibrocystic breast D. Breast cancer

Correct Answer is B

Explanation

A. Cyclic breast pain is related to the menstrual cycle and typically follows a pattern in relation to hormonal changes. It often starts in the luteal phase of the cycle and resolves with the onset of menstruation. Since the described pain is not associated with the menstrual cycle, this term is not appropriate for the given scenario.
B. Noncyclic breast pain is pain that is not related to the menstrual cycle and does not have a specific, cyclical pattern. It is often described as occurring independently of hormonal changes and can be associated with a variety of other factors, including infections, injuries, or other conditions affecting the breast tissue.
C. Fibrocystic breast changes refer to a condition characterized by lumpy, tender breasts with pain often related to hormonal changes. The pain and lumps can vary with the menstrual cycle, so it does not fit the description of noncyclic pain that is independent of the menstrual cycle.
D. While breast cancer can present with pain, particularly in advanced stages or in the presence of a mass, the term "breast cancer" is not used to describe the nature of the pain itself. It is a diagnosis rather than a descriptive term for pain characteristics.

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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 abnormality is depicted in the image below?

Correct Answer is B

Explanation

Breast pain that is not associated with the menstrual cycle and has no precipitating factors is documented using which term?

Correct Answer is B

Explanation

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