The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.
Client with restricted activity
Client who can ambulate
Client with a cast
Client with good nutrition
Client with urinary and fecal incontinence
Correct Answer : A,C,E
A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.
B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers
C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.
D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Malignant hypothermia: This is a rare but life-threatening reaction to certain medications used during anesthesia. It doesn't typically manifest with calf edema.
B. Pulmonary embolism: While pulmonary embolism can occur as a complication in some cases, it is characterized by symptoms like sudden shortness of breath, chest pain, and may not directly cause calf edema.
C. Acute compartment syndrome
Increasing edema in the calf of a client with multiple fractures of the leg is a manifestation of acute compartment syndrome. Acute compartment syndrome occurs when there is increased pressure within a muscle compartment, which can lead to reduced blood flow, nerve damage, and tissue hypoxia. The edema and increased pressure can compress blood vessels, nerves, and muscle tissue within the compartment, resulting in symptoms such as severe pain, edema, and potential vascular compromise.
D. Fat embolism syndrome: This syndrome can occur in clients with long bone fractures, but it is characterized by respiratory and neurologic symptoms, not isolated calf edema.
Correct Answer is D
Explanation
The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.
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