A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?
A decreased ability to communicate.
Thinning of the skin with loss of elasticity.
A 16 percent increase in overall body fat.
Calcium loss in the bones.
The Correct Answer is B
The correct answer is choice B: Thinning of the skin with loss of elasticity.
Choice A rationale:
While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:
Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.
Choice C rationale:
A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.
Choice D rationale:
Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Ineffective airway clearance.
Choice A rationale:
Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Correct Answer is B
Explanation
The correct answer is choiceB. Culture for sensitive organisms.
Choice A rationale:
C-reactive protein (CRP) levels are indicative of inflammation in the body and can help identify the presence of an infection. However, CRP levels do not provide specific information about the type of organism causing the infection, which is crucial for targeted treatment.
Choice B rationale:
A culture for sensitive organisms is essential in this scenario because it identifies the specific bacteria or other pathogens present in the wound. This information is critical for selecting the appropriate antibiotic therapy to treat the infection effectively.
Choice C rationale:
Serum albumin levels are important for assessing nutritional status and overall health, which can impact wound healing. Low albumin levels can indicate poor nutritional status and delayed wound healing, but they do not provide immediate information about the infection itself.
Choice D rationale:
Serum blood glucose (BG) levels are crucial for managing diabetes and can affect wound healing. High blood glucose levels can impair the immune response and slow down the healing process. However, like CRP, BG levels do not provide specific information about the type of infection present in the wound.
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