A nurse is assessing a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?
Increased collagen.
Decreased circulation.
Increased muscle mass.
Decreased serum calcium.
The Correct Answer is B
Choice A rationale:
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
Choice B rationale:
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
Choice C rationale:
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
Choice D rationale:
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
Choice B rationale:
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
Choice C rationale:
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
Choice D rationale:
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
Correct Answer is A
Explanation
Choice A rationale:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
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