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When assessing a client's skin, the nurse recognizes that of the susceptible areas, most pressure injuries occur over which bony prominence? Identify on the picture where you would assess this.

Answer and Explanation

The Correct Answer is "{\"xRanges\":[68.5593220338983,73.64406779661016],\"yRanges\":[55.125507581698336,62.88966357912063]}"

The sacrum is the most susceptible area for pressure injuries because it bears a significant amount of body weight when a client lies in a supine position for extended periods. This is because it is a bony prominence with minimal cushioning, so pressure is not well-distributed, increasing the risk of skin breakdown. Immobile clients also often remain in the same position for long periods, leading to reduced blood flow (ischemia) to the area. The sacral area is also commonly exposed to moisture from urine or feces in incontinent clients, which weakens the skin and increases the risk of injury.

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Correct Answer is B

Explanation

A. Otosclerosis: Otosclerosis refers to abnormal bone growth in the middle ear, leading to hearing loss, not vision problems. It affects hearing, not the eyes, and does not cause blurred or hazy vision.

B. Cataracts: Cataracts occur when the lens of the eye becomes clouded, leading to blurred or hazy vision, which is exactly what the client is describing. The clouding of the lens is a hallmark sign of cataracts, which typically cause gradual vision loss over time.

C. Presbycusis: Presbycusis is age-related hearing loss, not a visual issue. It typically manifests as difficulty hearing high-frequency sounds and is not associated with blurred vision or clouding of the lens.

D. Glaucoma: Glaucoma is characterized by increased intraocular pressure, which can lead to vision loss, but it typically causes peripheral vision loss, not blurred or hazy vision. The clouding of the lens described here is more indicative of cataracts than glaucoma.

A. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest. B. Measure two fingerbreadths below the acromion process. C. Ensure to find a place 2 inches away from the umbilicus and free of bruising. D. Measure a handbreadth above the knee and a handbreadth below the greater trochanter.

Correct Answer is D

Explanation

A. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest: This method is used to locate the ventrogluteal site, not the vastus lateralis.

B. Measure two fingerbreadths below the acromion process: This technique is used to identify the deltoid muscle for IM injections. It is not appropriate when the vastus lateralis is the intended site for medication administration.

C. Ensure to find a place 2 inches away from the umbilicus and free of bruising: This description refers to a subcutaneous injection in the abdomen, commonly used for medications like insulin or heparin, not for IM injections.

D. Measure a handbreadth above the knee and a handbreadth below the greater trochanter: This is the correct technique for locating the vastus lateralis muscle. It ensures the injection is given in the thickest part of the muscle, minimizing the risk of nerve or blood vessel injury.

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When assessing a client's skin, the nurse recognizes that of the susceptible areas, most pressure injuries occur over which bony prominence? Identify on the picture where you would assess this.

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Naxlex Comprehensive Predictor Exams

During an assessment, the nurse notices clouding of the lens of the left eye, and the client reports blurred and hazy vision in the eye. These findings suggest which of the following?

Correct Answer is B

Explanation

A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?

Correct Answer is D

Explanation

The nurse understands that patients who are continuously deprived of REM sleep are at highest risk for:

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