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 D
Explanation
Choice A rationale:
Piaget's formal operational stage is characterized by abstract thinking, hypothesis testing, and logical reasoning, but it does not include the development of object permanence. This stage typically occurs during adolescence, not in early childhood when object permanence is established.
Choice B rationale:
The preoperational stage is characterized by the development of symbolic thought and egocentrism but not object permanence. Object permanence starts to develop during the sensorimotor stage.
Choice C rationale:
Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events. It does not include the development of object permanence, which occurs in the earlier sensorimotor stage.
Choice D rationale:
Object permanence is a concept that develops during Piaget's sensorimotor stage, which typically occurs from birth to about two years of age. During this stage, children learn that objects continue to exist even when they are out of sight. They develop the ability to represent objects mentally and understand the concept of permanence.
Correct Answer is D
Explanation
Choice A rationale:
Spirituality can increase feelings of hopelessness. This statement is not accurate. In many cases, spirituality can provide comfort, support, and a sense of hope for individuals who are nearing the end of life. Many people turn to their faith and spirituality as a source of strength and consolation during difficult times.
Choice B rationale:
Spirituality can increase the desire to hasten death. This statement is not generally true. Spirituality often has the opposite effect by providing a sense of purpose and meaning in life, which can help individuals find reasons to continue living. While some individuals may grapple with complex feelings related to death, it's not a typical outcome of embracing spirituality.
Choice C rationale:
Spirituality can increase depression. This statement is not accurate. Spirituality can actually serve as a source of emotional support and resilience for individuals facing the end of life. It can help individuals cope with their emotions and provide a sense of peace and comfort.
Choice D rationale:
Spirituality can increase the quality of life. This statement is correct. Spirituality often plays a positive role in the lives of individuals nearing the end of life. It can enhance the quality of life by providing emotional and psychological support, promoting a sense of purpose, and helping individuals find comfort and peace during this challenging time.
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