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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While understanding risk factors for osteoporosis is important, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
Choice B rationale
While constipation due to immobility can be a concern for clients with osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
Choice C rationale
Identifying home safety hazards to be resolved immediately is the highest priority for an older adult client diagnosed with osteoporosis. Osteoporosis increases the risk of fractures, and falls are a common cause of fractures in older adults. Therefore, ensuring a safe environment is crucial.
Choice D rationale
While adding calcium-rich foods to the daily diet can help manage osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.
Correct Answer is B
Explanation
Choice A rationale
While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.
Choice B rationale
Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.
Choice C rationale
Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.
Choice D rationale
Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.
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