A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which 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: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

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Correct Answer is D

Explanation

Choice A reason: Heat and cold therapy can help manage symptoms but are not directly related to health promotion and teaching.

Choice B reason: Avoiding foods containing purine is more related to conditions like gout, not rheumatoid arthritis.

Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen rheumatoid arthritis symptoms over time.

Choice D reason: Prevention through nutrition and exercise is a key component of health promotion and teaching for clients with rheumatoid arthritis, as it can help manage symptoms and improve overall health.

A. Allow for menu deviations. B. Set precise mealtimes. C. Encourage exercise. D. Monitor trips to the restroom. E. Provide family education on the condition. F. Weigh the patient twice weekly. G. Acknowledge feelings of anxiety.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

Choice A Reason: Allowing for menu deviations can help accommodate the patient’s preferences and encourage eating, which is crucial for recovery from emaciation.
Choice B Reason: Setting precise mealtimes can provide structure and consistency, which may help the patient establish regular eating habits.
Choice C Reason: Encouraging exercise is not appropriate at this stage due to the patient’s bradycardia and low BMI, which indicate a high risk for physical complications.
Choice D Reason: Monitoring trips to the restroom is important to prevent purging behaviors, which can be a concern in patients with eating disorders.
Choice E Reason: Providing family education on the condition is essential to ensure that the family understands the patient’s needs and how to support her recovery.
Choice F Reason: Weighing the patient twice weekly can help monitor her progress and adjust the treatment plan as needed.
Choice G Reason: Acknowledging feelings of anxiety is important for addressing the psychological aspects of the patient’s condition and promoting a supportive environment.

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A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

Correct Answer is D

Explanation

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

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