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

Answer and Explanation

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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Correct Answer is B

Explanation

A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.

B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.

C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.

D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.

A. Increased thickness of the subcutaneous skin layer B. Changes in the character and quantity of bacterial skin flora C. Increased time required for wound healing D. Increased elasticity of the skin

Correct Answer is C

Explanation

A. Increased thickness of the subcutaneous skin layer - Aging typically results in thinning of the skin and subcutaneous tissue, making older adults more vulnerable to pressure ulcers rather than having increased thickness.

B. Changes in the character and quantity of bacterial skin flora - This is a common age-related change; however, it is not directly related to the course of treatment for a sacral pressure ulcer. Proper wound care can mitigate the impact of changes in skin flora.

C. Increased time required for wound healing - Aging often leads to a decline in the body's ability to repair and regenerate tissues, which can prolong the healing process of wounds, including pressure ulcers. Older adults may experience delayed wound healing compared to younger individuals.

D. Increased elasticity of the skin - Skin elasticity decreases with age, making older adults more susceptible to skin breakdown and pressure ulcers due to reduced skin resilience and ability to redistribute pressure. Increased elasticity would not affect the course of treatment positively but rather negatively in this context.

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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.

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