Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.
Applies powder after drying the skin.
Has been NPO for four days.
Bathes twice a week.
Has hypertension.
The Correct Answer is B
A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead
to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.
Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.
Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.
Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reminiscing about the spouse with significant others. This is an important need for a widowed client during the grieving period following the death of the client’s spouse because it helps them process their loss, express their emotions, and honor their memories. Reminiscing can also provide comfort, support, and meaning to the bereaved.
Choice B. Self-indulgence in order to fill the emptiness left by the spouse’s death is wrong because it can be unhealthy, addictive, or harmful to the client’s well-being. Self-indulgence may also prevent the client from coping with their grief in a constructive way.
Choice C. Reassurance that the client did all that could be expected for their spouse is wrong because it may imply that the client is responsible for their spouse’s death or that they could have prevented it.
This may increase the client’s guilt, regret, or self-blame. Reassurance should focus on the client’s strengths, resilience, and coping skills.
Choice D. Engagement in activities that will take the client’s mind off the loss of the spouse is wrong because it may suggest that the client should avoid or deny their grief.
This may interfere with the healing process and lead to unresolved or complicated grief. Engagement in activities should be balanced with time for reflection, mourning, and self-care.
Normal ranges for grief vary depending on the individual, the relationship, and the circumstances of the death. However, some general guidelines are that grief can last from a few months to several years and that it may involve physical and emotional symptoms such as trouble sleeping, loss of appetite, difficulty concentrating, crying, sadness, anger,
Correct Answer is C
Explanation
Orient the client to the arrangement of the room to promote independence. This strategy helps the client who is blind to navigate the environment safely and confidently. It also shows respect for the client’s autonomy and dignity.
Choice A is wrong because speaking loudly is not necessary for a client who is blind, unless they also have hearing impairment. Speaking loudly may imply that the client is less intelligent or capable, which is not true.
Choice B is wrong because touching the client prior to speaking may startle or frighten them. It is better to identify oneself verbally and ask for permission before touching the client.
Choice D is wrong because keeping the bed in the highest position may increase the risk of injury if the client tries to get out of bed alone. It also restricts the client’s mobility and independence, which may affect their self-esteem and quality of life.
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