Which patient is most at risk for pressure ulcer formation?
The patient with a poor appetite for 3 days
The patient with a raised red rash on the right shin
The patient with a capillary refill less than 2 seconds
The patient with fecal incontinence
The Correct Answer is D
Choice A reason: Poor appetite for 3 days may lead to nutritional deficits, increasing ulcer risk long-term, but immediate risk is lower. Fecal incontinence causes ongoing moisture, making it a higher priority risk factor.
Choice B reason: A raised red rash on the shin may indicate irritation or infection but does not directly contribute to pressure ulcer formation. Incontinence-related moisture is a greater risk, making this incorrect.
Choice C reason: Capillary refill less than 2 seconds indicates normal perfusion, not a risk for pressure ulcers. Poor perfusion increases risk, but incontinence’s moisture directly threatens skin integrity, making this incorrect.
Choice D reason: Fecal incontinence increases pressure ulcer risk by exposing skin to moisture and irritants, causing maceration and breakdown. This is a primary risk factor, making it the patient most at risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Carrying a pen and paper aids written communication, but expressive aphasia impairs verbal expression, not necessarily writing. A picture board is more effective for nonverbal communication, making this less optimal for immediate needs in expressive aphasia.
Choice B reason: Using a picture board for nonverbal communication is the best strategy for expressive aphasia, as it allows the patient to convey needs visually when verbal speech is impaired. This statement reflects effective understanding of communication alternatives, making it correct.
Choice C reason: Expecting full speech recovery in 1 day is unrealistic, as expressive aphasia recovery varies and often requires prolonged therapy. This statement indicates a misunderstanding of stroke recovery, making it incorrect for effective teaching.
Choice D reason: Thickening drinks prevents aspiration in dysphagia, not directly related to expressive aphasia, which affects speech production. This statement addresses a different stroke complication, making it irrelevant to the teaching focus on communication.
Correct Answer is B
Explanation
Choice A reason: Tiny blood clots in the urine (hematuria) suggest urinary tract infection or trauma, not directly related to incontinence or mobility issues. Skin irritation from prolonged urine exposure is more expected, making this finding less likely in this patient patient.
Choice B reason: Skin irritation and redness in the perineal area are expected in urinary incontinence and impaired mobility, as prolonged moisture and pressure cause maceration and dermatitis. This is a common complication requiring skin protection, making it the correct finding finding.
Choice C reason: Increased urinary frequency may occur in incontinence but is not the primary concern compared to skin damage from constant moisture due to impaired mobility. Perineal irritation is a more direct consequence, making this less specific to the described scenario.
Choice D reason: Decreased urine specific gravity indicates dilute urine, unrelated to incontinence or mobility. It may occur in overhydration, but skin irritation from urine exposure is the most relevant finding in this patient context, making this incorrect incorrect.
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