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 B
Explanation
This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-
being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.
Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.
It is not a priority over fluid volume deficit.
Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.
Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.
Correct Answer is A
Explanation
A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.
Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.
Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.
Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.
Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.
Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
