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 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.

A. Tuberculin skin test B. Low socioeconomic status. C. Complete blood count (CBC) D. Male gender E. Aral blood gases (ABG) F. Chest x-ray

Correct Answer is ["A","C","E","F"]

Explanation

A. This is a diagnostic test used to determine if a client has been exposed to tuberculosis (TB). It is a secondary data source because it provides information about potential TB infection which can affect respiratory health.
B. While low socioeconomic status can impact health and access to healthcare, it is not a direct diagnostic tool or test for assessing the respiratory system. Instead, it is a social determinant that may influence health outcomes but does not provide direct data about the respiratory system itself.
C. A CBC is a laboratory test that provides information on various components of the blood, including red blood cells, white blood cells, and platelets. It can give insights into conditions that might affect the respiratory system, such as anemia or infections.
D. Male gender is a demographic characteristic rather than a diagnostic or data-gathering tool. While gender may influence the prevalence of certain respiratory conditions, it does not itself provide direct information or data about respiratory health.
E. ABG tests measure the levels of oxygen and carbon dioxide in the blood, as well as the blood’s pH balance. This test provides crucial information about a client’s respiratory function and is considered a secondary data source because it results from a specific diagnostic test rather than direct observation or physical assessment.
F. A chest x-ray is a diagnostic imaging test that provides detailed pictures of the lungs and chest cavity. It can reveal abnormalities such as infections, tumors, or fluid in the lungs. Since it is a test conducted outside of direct physical examination, it is classified as a secondary data source.

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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

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

The medical-surgical charge nurse is conducting a training workshop for a group of new nurses. Which information would the nurse include in the training as secondary data sources of a client's respiratory system? Select all that apply.

Correct Answer is ["A","C","E","F"]

Explanation

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