A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral ulcer with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A reason: Thick, dry, dark areas on heels suggest chronic skin changes, not early pressure ulcers. Persistent redness over bone is the earliest sign (Stage 1). This indicates later damage, per pressure injury staging and prevention protocols in nursing care for immobile clients.

Choice B reason: Broken skin indicates a Stage 2 pressure ulcer, beyond the earliest stage. Persistent redness (Stage 1) signals initial tissue compromise. Broken skin requires intervention but is not the earliest sign, per pressure ulcer assessment and prevention standards in nursing practice.

Choice C reason: Persistent redness over bone is the earliest sign of a Stage 1 pressure ulcer, indicating tissue compromise due to pressure. Early intervention prevents progression in bedrest clients with heart failure, per pressure injury prevention and skin assessment protocols in nursing care.

Choice D reason: A superficial sacral ulcer (Stage 2) is more advanced than persistent redness (Stage 1), the earliest sign. Redness allows earlier intervention to prevent ulceration. Ulcers indicate progression, per pressure ulcer staging and prevention guidelines for immobile clients in nursing.

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Correct Answer is B

Explanation

Choice A reason: Feeling guilty about drinking (CAGE’s “G”) suggests awareness of problematic use, indicating psychological dependence. However, guilt is less specific than morning drinking, as it may occur in binge or social drinking without physical addiction. Morning drinking reflects physiological dependence, a stronger marker of chronic alcoholism.

Choice B reason: Needing a morning drink (CAGE’s “E” for eye-opener) indicates physical dependence, a hallmark of alcoholism. This reflects tolerance and withdrawal, where alcohol stabilizes GABA/glutamate imbalances to prevent symptoms like tremors. It’s the most specific indicator, showing the body’s reliance on alcohol, central to alcoholism’s pathophysiology.

Choice C reason: Annoyance at drinking criticism (CAGE’s “A”) suggests defensiveness, possibly indicating psychological dependence. It’s less specific than morning drinking, reflecting social dynamics rather than physical addiction. Alcoholism involves physiological changes, and morning drinking directly demonstrates the body’s need for alcohol to manage withdrawal, making this less indicative.

Choice D reason: Feeling the need to cut down (CAGE’s “C”) shows recognition of excessive drinking but is less specific than morning drinking, which signifies physical dependence from chronic alcohol-induced neurotransmitter changes. This question captures awareness but not the physiological addiction that morning drinking indicates, central to diagnosing alcoholism.

A. Oatmeal, raisins, and fruit with skin. B. Potatoes, low-fat breads, and applesauce. C. Chicken, rice, and wheat products. D. Lean beef, salads, and baked potatoes.

Correct Answer is A

Explanation

Choice A reason: Oatmeal, raisins, and fruit with skin are high in fiber, reducing colorectal cancer risk by promoting bowel regularity and reducing carcinogen exposure. This aligns with dietary prevention strategies, per oncology and gastrointestinal health guidelines in nursing education.

Choice B reason: Potatoes, low-fat breads, and applesauce are low in fiber, offering less protection against colorectal cancer. High-fiber foods like oatmeal and fruit are preferred to reduce risk, per dietary recommendations and cancer prevention protocols in nursing care.

Choice C reason: Chicken, rice, and wheat products provide moderate fiber but lack the high-fiber content of oatmeal and fruit with skin, which better reduce colorectal cancer risk. Fiber is key, per oncology and dietary prevention standards in nursing education.

Choice D reason: Lean beef, salads, and baked potatoes offer some benefits, but beef may increase cancer risk. High-fiber oatmeal, raisins, and fruit are more effective for prevention, per colorectal cancer dietary guidelines and oncology prevention protocols in nursing care.

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A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

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