The nurse is planning care for a client who was admitted to the acute care unit with a fractured left hip. A family member found the client at the bottom of a flight of steps in the evening. The client states, "I laid there all day and could not get anything to drink since I woke up." The transport team found that the client's leg was out of alignment and that the client was incontinent of urine. The client was oriented, tearful, and speaking in a weak voice. Medications taken earlier that day included:
• An antihypertensive medication (dosage was increased yesterday as prescribed by the healthcare provider)
A potassium supplement
• Aspirin 81 mg orally daily
Which assessment information given upon admission directs the nurse to assess for pressure injuries? (Select all that apply)
Urinary incontinence
No access to fluids
Inability to change position after falling
Self-administration of antihypertensive medication
Inability to give specific details about activities prior to falling
Correct Answer : A,B,C
A. Urinary incontinence. Exposure to moisture from urine leads to skin maceration and the breakdown of the protective acid mantle. This chemical irritation increases friction and shear susceptibility, making the epidermis highly vulnerable to Stage 1 and 2 pressure injuries. Moisture-associated skin damage often precedes deeper tissue ischemia in immobilized geriatric patients.
B. No access to fluids. Dehydration significantly impairs skin turgor and reduces the perfusion of the dermal layers. Inadequate fluid volume compromises the transport of nutrients and oxygen necessary for maintaining cellular integrity under pressure. Tissue that is poorly hydrated is less resilient to mechanical stress and succumbs faster to necrosis.
C. Inability to change position after falling. Prolonged unrelieved pressure against a hard surface causes localized hypoxia and obstructive ischemia in the tissues overlying bony prominences. Without reperfusion through repositioning, cellular death begins within hours of continuous compression. This lack of mobility is the fundamental mechanical cause for the development of pressure-related ulcers.
D. Self-administration of antihypertensive medication. The act of taking medication does not directly contribute to the mechanical or physiological breakdown of skin tissue. While the drug effects might contribute to the fall, the administration process itself is irrelevant to pressure injury risk. It does not provide assessment data regarding the current state of tissue integrity.
E. Inability to give specific details about activities prior to falling. Cognitive confusion or amnesia may indicate neurological impairment or trauma but does not physically damage the integumentary system. While it suggests the patient cannot self-report discomfort, it is a neurological assessment finding rather than a direct risk factor for pressure sores. It does not dictate specific skin assessment protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
A. Edema: Venous insufficiency leads to poor return of blood from the lower extremities, causing fluid accumulation in the interstitial tissues. This manifests as leg swelling (edema), which is a hallmark of venous disease.
B. Pale wound bed: A pale wound bed is more characteristic of arterial ulcers, which result from poor oxygenation and perfusion. Venous ulcers usually have a ruddy, beefy red wound bed due to adequate arterial inflow but impaired venous return.
C. Itchy dry scaly skin: Chronic venous stasis causes skin changes such as stasis dermatitis. Patients often report itching, dryness, and scaling due to impaired circulation and inflammatory changes in the skin.
D. Large amount of drainage: Venous ulcers typically produce copious exudate because of high hydrostatic pressure in the veins, which forces fluid out into the wound bed. This is one of the distinguishing features compared to arterial ulcers, which are usually dry.
E. Wound edges surrounded by calloused tissue: Calloused wound edges are more typical of neuropathic/diabetic ulcers, especially on pressure points of the foot. Venous ulcers usually have irregular, shallow edges without callus formation.
F. Hyperpigmentation of the skin surrounding the ulcerated area: Long-standing venous hypertension causes red blood cells to leak into surrounding tissues. Breakdown of hemoglobin deposits hemosiderin, leading to brownish discoloration (hyperpigmentation) around the ulcer site.
Correct Answer is ["10"]
Explanation
Prescription: cefixime 200 mg PO
Available: 100 mg per teaspoon
First convert teaspoons to mL.
1 teaspoon = 5 mL
So:
100 mg = 5 mL
200mg /100mg× 5ml=10ml
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