Which client is at greatest risk for developing a pressure injury?
A client who exercises daily
An immobile client
A client with mild headache
A client with seasonal allergies
The Correct Answer is B
Rationale:
A. A client who exercises daily is at low risk for pressure injuries. Regular movement promotes adequate circulation, reduces prolonged pressure on any one area, and maintains skin integrity. Activity is actually protective against pressure injury development.
B. An immobile client is at the greatest risk for pressure injuries. Pressure injuries develop when there is prolonged pressure over bony prominences (e.g., sacrum, heels, hips), which impairs blood flow and leads to tissue ischemia and breakdown. Immobility prevents repositioning, resulting in sustained pressure, decreased perfusion, and eventual tissue damage. Additional contributing factors often include moisture, friction, shear, and poor nutrition, but immobility is the primary and most significant risk factor.
C. A client with a mild headache has no direct risk for pressure injury unless other factors (like immobility) are present. A headache does not affect circulation, mobility, or skin integrity.
D. A client with seasonal allergies is not at increased risk for pressure injuries. Allergies may cause discomfort or respiratory symptoms but do not impair mobility or tissue perfusion in a way that contributes to pressure injury formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Rationale:
A. Lymph nodes that are freely moveable under the skin are typically normal. Mobility indicates that the node is not infiltrated by fibrotic tissue or malignant cells. Moveable nodes may shift slightly during palpation and are usually soft or rubbery.
B. Smooth lymph nodes are generally normal. Irregular, nodular, or spiculated nodes are more concerning for pathology. Smoothness alone does not indicate abnormality.
C. Non-tender lymph nodes are often normal, particularly if they are small and soft. Tenderness is usually associated with acute infections, such as localized cellulitis or mastitis. Therefore, non-tender nodes in isolation are not considered abnormal.
D. Hard lymph nodes are abnormal. Hardness suggests that the node may be infiltrated with malignant cells or fibrotic tissue, which can occur in breast cancer metastasis or chronic infections. Hard nodes are less compressible and may be associated with an irregular surface.
E. Fixed, immobile lymph nodes are also abnormal. Normal nodes are freely movable; when nodes are adherent to surrounding tissues, it can indicate malignancy, fibrosis, or metastatic spread. Fixed nodes do not shift easily with palpation and require prompt medical evaluation.
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. A severe headache following trauma may indicate a subdural or epidural hematoma, intracranial hemorrhage, or other serious brain injury. Any new or worsening headache after a head injury warrants immediate evaluation.
B. Altered mental status, including confusion, disorientation, or decreased level of consciousness, can signal increased intracranial pressure, stroke, infection, or other neurological emergencies. This is considered a red flag symptom.
C. A sudden, severe “thunderclap” headache reaching maximum intensity within seconds to minutes can indicate subarachnoid hemorrhage or other vascular emergencies. Rapid onset headaches should be treated as urgent.
D. Neck stiffness or rigidity, especially when associated with headache, may suggest meningitis or subarachnoid hemorrhage. This combination requires immediate assessment and intervention.
E. Headaches that improve with rest are generally tension-type headaches or benign causes and are not considered red flag symptoms. While they may still require evaluation, they do not indicate an urgent or emergent condition.
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