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 C
Explanation
Choice A rationale:
Dysphagia is a difficulty or discomfort with swallowing and is not a complication of diverticulitis. Diverticulitis typically involves inflammation or infection of diverticula in the colon and may present with symptoms such as abdominal pain, fever, and changes in bowel habits, but dysphagia is not a characteristic feature.
Choice B rationale:
Ulcerative colitis is a distinct inflammatory bowel disease and is not a complication of diverticulitis. These conditions have different causes and affect different parts of the digestive tract. While both conditions can cause abdominal discomfort, they are not directly related.
Choice C rationale:
Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.
Choice D rationale:
Crohn's disease is a separate inflammatory bowel disease and is not a complication of diverticulitis. Crohn's disease can affect any part of the digestive tract, whereas diverticulitis typically occurs in the colon. They have distinct clinical features and treatment approaches. .
Correct Answer is D
Explanation
The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."
Choice A rationale:
- Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
- Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
- It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.
Choice B rationale:
- Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
- Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
- Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.
Choice C rationale:
- While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
- The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
- More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.
Choice D rationale:
- Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
- Other potential symptoms of diabetic retinopathy include:
- Blurred vision
- Floaters (dark specks or strings that move across the visual field)
- Difficulty seeing at night or in low light
- Loss of central vision
- Distortion of colors
- Blind spots
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.