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 A

Explanation

Choice A rationale

In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.

Choice B rationale

While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice C rationale

The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice D rationale

The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

A. Asthma related to environmental factors B. COPD related to smoking C. Pneumonia related to bacterial infection D. Tuberculosis related to Mycobacterium tuberculosis

Correct Answer is A

Explanation

Choice A rationale

The patient’s history of asthma, previous hospitalizations for asthma-related symptoms, and the current presentation of difficulty breathing and wheezing suggest that she is likely experiencing an asthma exacerbation related to environmental factors. Asthma is a chronic condition that can cause symptoms such as wheezing, shortness of breath, and chest tightness, which the patient is currently experiencing. Environmental factors such as allergens, air pollution, and changes in weather can trigger asthma symptoms.

Choice B rationale

While smoking is a major risk factor for COPD, the patient denies smoking. Additionally, COPD is more common in older adults, and the patient is only 22 years old. Therefore, it is less likely that her symptoms are due to COPD.

Choice C rationale

Pneumonia is typically associated with additional symptoms such as fever, cough with phlegm, and chest pain. The patient’s symptoms do not align with a typical presentation of pneumonia.

Choice D rationale

Tuberculosis is a bacterial infection that typically presents with a chronic cough, weight loss, and night sweats. The patient’s symptoms do not align with a typical presentation of tuberculosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Correct Answer is A

Explanation

Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

Correct Answer is A

Explanation

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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?