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 ["A","B","C","D"]
Explanation
Choice A rationale
A rotator cuff injury could be a possibility given the patient’s age and the nature of the fall. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, and injuries to this area are common in falls where the shoulder takes the impact.
Choice B rationale
A humeral fracture could also be a possibility. The humerus is the bone in the upper arm, and it can be fractured in falls, especially in older adults who may have weaker bones.
Choice C rationale
A concussion could be a possibility given that the patient hit his head on the wall. Symptoms of a concussion can include nausea and fatigue, which the patient is experiencing.
Choice D rationale
A knee sprain could be a possibility given that the patient is experiencing pain in his right knee. Sprains occur when the ligaments, which are the bands of tissue that hold bones together, are stretched or torn.
Correct Answer is C
Explanation
Choice A rationale
Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.
Choice B rationale
While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.
Choice C rationale
The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.
Choice D rationale
Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.
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