A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.
Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral pressure injury with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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Correct Answer is B

Explanation

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

A. Client’s healthcare power of attorney. B. Currently prescribed medications. C. Fall at home as reason for admission. D. Increasing confusion of the patient.

Correct Answer is D

Explanation

Choice A rationale

While the client’s healthcare power of attorney is important information, it is not the most critical piece of information to report in this situation. The immediate concern is the client’s change in mental status and potential medical emergency.

Choice B rationale

The nurse should be aware of the client’s currently prescribed medications, but this information does not take precedence over the client’s sudden onset of confusion and agitation. Immediate action is needed to address the client’s altered mental status.

Choice C rationale

While the reason for the client’s admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client’s acute change in mental status.

Choice D rationale

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client’s immediate needs.

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A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

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A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.
Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?